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LIBRARY OF CONGRESS. 






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UNITED STATES OF AMERICA. 



CLINICAL HAND-BOOK 



Diseases of Women 



W. SYMINGTON BROWN, M.D. 

Member of the Cjyncecolo^ical Society of Bostojt, Fellow of the Mass. Medical 
Society, etc. 



1- 



V' 



THE HIGHEST AIM OF OUR ART MUST BE THE GREATEST POSSIBLE GENERALIZATION OF DIS- 
EASES, AND THE GREATEST POSSIBLE INDIVIDUALIZATION OF OUR PATIENTS." 



'COPYR, 



^x\._^ ^ op \,VAc u<nG^^ > 



N.^w yo:kk 

WILLIAM WOOD AND COMPANY 
1882 



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Copyright 

WILLIAM WOOD & COMPANY 

1882 



Trow's 

Printing and Bookbinding Company 

201-213 East \-ztk Street 

NEW YORK 



PREFACE. 



This little book does not claim to be a treatise. Many of 
the more recondite aspects of disease are purposely omitted. 
It is intended as a practical guide on most of the diseases 
peculiar to women, for the use of medical students and 
country practitioners. An effort has been made to con- 
centrate the best that has been written on each subject, 
including the old masters, whose works the present genera- 
tion are too much disposed to underrate. Most of the 
illustrative cases are taken from the author's note-books; 
the rest are duly credited. 

Puerperal diseases are included, or, more correctly, those 
which precede, accompany, or follow the puerperal state. 
The great bulk of female diseases are in some way con- 
nected with conception ; many of them follow abortion or 
even confinement at term. In these two chapters the author 
is specially indebted to the masterly work of Dr. Fordyce 
Barker. 

A similar excuse may be urged for inserting chapters on 
gonorrhoea and syphilis. The work would not be complete 
without them. Those who wish to pursue these subjects 
farther will find many interesting details in Ziemssen's 
Cyclopaedia, Vol. III., and in " Surgical Diseases of the 
Genito-Urinary Organs," by Drs. Van Buren and Keyes. 

It may not be superfluous to point out that the author has 
endeavored, as far as possible, to group the different topics 
under a fourfold arrangement. Thus, the aUied diseases, 
their varieties, symptoms, and remedies, are generally ar- 



iv PREirACE. 

ranged in groups of four, or some multiple of two. This 
with a view to aid the memory. 

In our treatment of diseases of women we do not take 
mental phenomena sufficiently into account. Many patients 
are mentally diseased who would scarcely be proper inmates 
of a lunatic asylum. Long-continued pain reacts upon the 
mind, and finally upsets it. We meet with cases in which 
credulity is carried to an extent scarcely compatible with 
sanity. Hence an additional reason for early attention to 
female complaints. Replacing a dislocated ovary, or repair- 
ing a lacerated cervix, may also save a mind from wreak. 

The author acknowledges his special indebtedness to the 
works of T. Spencer Wells, F.R.C.S., and Drs. Sims, 
Emmet, Thomas, and Skene. Dr. Goodell has recently 
directed attention to what may be called preventive hygiene 
for w^omen. It is a great pity that public conveniences for 
ladies are so scarce in large cities. Even in country towns 
there is ample room for improvement. Much suffering and 
disease might be prevented by arranging w^ater-closets and 
latrines in such a way that the natural modesty of the sex 
would not be outraged in using them. Dry-earth closets, in 
the country, fulfil every requirement ; but their use at pres- 
ent is very limited. 

I would also respectfully suggest that it is a part of the 
physician's duty to prevent disease, when he can, by timely 
hints to young people recently married about the hygiene of 
reproduction. 

For the article on Clitoridectomy, in Chapter XXIII., I 
am indebted to my friend, Dr. Henry O. Marcy, Boston. 

A large portion of the woodcuts (instruments) have been 
kindly furnished by Messrs. Codman & Shurtleff, Boston, 
who can supply the originals. 

Stoneham, Mass., January, 1882. 



CONTENTS. 



PAGE 

Illustrations ix 

Works Consulted , xi 

Dictionary , xv 

CHAPTER I. 

Anatomy of the Genital Organs 17 

The female bladder, 18; urethra, 19; vagina, 21; uterus, 22; ovaries, 
27 ; Fallopian tubes, 29 ; hymen, 29 ; clitoris, 30 ; mammary glands, 
30. 

CHAPTER II. 

Instruments, and How to Use Them 32 

Mode of examination, 33 ; insertion of speculum, 35 ; cleansing the 
parts, 37 ; application of remedies, 39 ; remedies applied by the 
patient, 40. 

CHAPTER III. 
•Vulvitis, etc ; 42 

Vulvitis, 42 ; vaginitis, 43 ; pruritus vulvae, 44 ; leucorrhoea, 45. 

CHAPTER IV. 
Vaginismus, etc 49 

Vaginismus, 49 ; dyspareunia, 50 ; masturbation, 51 ; atresia vaginse, 53. 

CHAPTER V. 

Amenorrhcea, etc ^. 58 

Amenorrhoea, 58 ; dysmenorrhoea, neuralgic, 62 ; dysmenorrhoea, in- 
flammatory, 6^ ; dysmenorrhoea, obstructive, 64 ; dysmenorrhoea, 
membranous, 65; menorrhagia, 66; metrorrhagia, 68. 



VI CONTENTS. 

CHAPTER VI. 

PAGE 

Inflammation and Laceration of Cervix Uteri 70 

CHAPTER VII. 
Metritis, Endometritis 75 

Metritis, 75 ; endometritis, 79. 

CHAPTER VIII. 
Pelvic Peritonitis and Cellulitis 85 

Pelvic peritonitis, 85 ; pelvic cellulitis, 86. 

CHAPTER IX. 
Pelvic Abscess, etc 88 

Pelvic abscess, 88 ; pelvic haematocele, 90 ; septicaemia, 92 ; pyaemia, 93. 

CHAPTER X. 

Retroversion, etc 95 

Retroversion, 95 ; retroflexion, 98 ; anteversion, 99 ; anteflexion, loi. 

CHAPTER XL 

Prolapsus Uteri, etc 103 

Prolapsus uteri, 103 ; procidentia, 104 ; elongation of cervix, 105 ; in- 
version, 109. 

CHAPTER XII. 

Uterine Tumors 114 

Subserous fibroids, 114; submucous fibroids, 114; interstitial fibroids, 
114; polypi, 115. 

CHAPTER XIIL 

Ovarian Tumors 124 

History, 124 ; pathology, 125 ; diagnosis, 126 ; ovariotomy, 131. 

CHAPTER XIV. 

Vaginal Ovariotomy, etc 141 

Vaginal ovariotomy, 141 ; Battey's operation, 143. 



CONTENTS. vii 



CHAPTER XV. 

PAGE 

Puerperal Diseases 145 

Puerperal fever, 145; convulsions, 147; insanity, 150; mastitis, 151; 
mastodynia, 152; chapped nipples, 153; agalactia, 154; galactor- 
rhoea, 155 ; phlegmasia dolens, 156 ; subinvolution, 157, 



CHAPTER XVI. 

Puerperal Diseases ( Continued) 160 

Abortion, 160; extra-uterine gestation, 163; mole pregnancy, 166; 
puerperal hemorrhage, 167 ; persistent vomiting, 168 ; ptyalism, 
171 ; puerperal lacerations, 172 ; relaxation of pelvic joints, 174 ; 
coccyodynia, 175 ; thrombosis and embolism, 176, 

CHAPTER XVII. 

Vaginal Fistula , 178 

Vesico- vaginal fistula, 178 ; entero -vaginal fistula, 181. 

CHAPTER XVIII. 

Diseases of Bladder and Urethra 184 

Cystitis, 184; stone in the bladder, 189; urethritis, 190; urethral tu- 
mors, 191 ; urethral stricture, 192 ; urethral prolapsus, 194. 

' CHAPTER XIX. 

Diseases of the Rectum 196 

Hemorrhoids, 196; anal fissure, 198; rectal polypus, 199; rectocele, 
200. 

CHAPTER XX. 
Gonorrhcea 202 

Gonorrhoeal rheumatism, 205. 

_ CHAPTER XXL 
Syphilis , 206 

Chancroid, 206 ; chancre, 208 ; constitutional syphilis, 210 ; secondary 
syphilis, 210; tertiary syphilis, 213; hereditary syphilis, 215. 



viii CONTENTS. 



CHAPTER XXII. 

PAGE 

Cancer 218 

Cancer of the uterus, 219; epithelioma of the cervix, 221 ; cancer of the 
ovary, 222 ; cancer of the vagina, 222 ; cancer of the breast, 224. 



CHAPTER XXIII. 

Chlorosis, etc 227 

Chlorosis, 227; neurasthenia, 228; ovaritis, 229; clitoridectomy, 231. 



CHAPTER XXIV. 

Sterility, Hysteria 234 

Sterility, 234 ; hysteria, 236. 



Index , 239 



ILLUSTRATIONS. 



FIGURE PAGE 

1. Section of Pelvic Organs (after Junker) 23 

2. Perpendicular View of Pelvic Organs (after Savage) 28 

3. Chadwick's Office Table 35 

4. Cusco's Speculum 35 

5. Fergusson's Speculum 36 

6. Sims' Speculum , 36 

7. Neugebauer's Speculum, nested 36 

8. Neugebauer's Speculum, in position . . . i 37 

9. Hard-Rubber Syringe 37 

10. Split Probang 38 

1 1. Simpson's Uterine Sound 38 

12. Lente's Silver Probe 38 

13. Glass Pipette ' 39 

14. Vaginal Douche 40 

15. Sims' Vaginal Dilator 50 

16. Pinkham's Scarificator 63 

17. Buttles' Intra-uterine Syringe 66 

18. Buttles' Intra-uterine Syringe, covered with cotton. 66 

19. Sims' Sharp Ciirette 68 

20. Ellinger's Dilator 69 

21. Double- current Catheter 76 

22. Hodge's Lever Pessary . 78 

23. Block-tin Pessary 79 

24. Cupping Cylinder ; 83 

25. Cutter's Retroversion Pessary, in situ 96 

26. Cutter's Anteversion Pessary* 100 

zf. Cutter's Ring Pessary for Prolapsus 105 



X • ILLUSTRATIONS. 

FIGURE PAGE 

28. Diagram of Cervix Uteri (after Schroeder) 106 

29. Paquelin's Thermo-Cautery 107 

30. Polypus Forceps , 116 

31. Wire Ecraseur 1 16 

32. Sponge-Tents 117 

33. Tubes for Ecraseur 119 

34. S)rphon Trocar 129 

35. Wooden Clamp, plain 135 

36. Wooden Clamp, curved 135 

37. Abscess Lancet 151 

38. Skene's Reflux Catheter 191 



ERRATUM. 
On page 31, line 6, for hypertrophy read atrophy. 



WORKS CONSULTED. 



Books. 

Diseases Peculiar to Women. Dr. Gooch. London, 1831. 

Diseases Peculiar to Women. Dr. S. Ashvvell. London, 1848. 

Surgical Diseases of Women. Baker Brown, F.R.C.S. Reprint, 1856. 

Diseases of Women. Dr. Churchill. Reprint, 1857. 

Signs of Pregnancy. Dr. Montgomery. Reprint, 1857. 

Inflammation of the Uterus. Dr. Bennett. Reprint, i860. 

Diseases of Women. Dr. Meigs. Philadelphia, 1859. 

Diseases of Women. Dr. Hodge. Philadelphia, i860. 

Diseases of Women. Prof. Scanzoni. New York, 1861. 

Lectures on Diseases of Women. Sir James Y. Simpson. Reprint, 1863. 

Lectures on the Diseases of Women. Dr. West. London, 1864. 

Acton on the Reproductive Organs. Reprint, 1865. 

Clinical Notes on Uterine Surgery. Dr. J. Marion Sims. New York, 1867. 

Diseased of Women. Dr. Graily Hewitt. Reprint, 1868. 

Diseases of Women. Prof. Byfoi-d. Philadelphia, 1867. 

Chronic Inflammation and Displacements, Prof. By ford. Philadelphia, 1871. 

Vesico-Vaginal Fistula. Dr. Emmet. New York, 1868. 

Pathological Anatomy of Female Sexual Organs. Dr. Klob. Reprint, 1868. 

Clinical Memoirs on Diseases of Women. Dr. McClintock. Dublin, 1863. 

Perimetritis and Parametritis. Dr. J. Mathews Duncan. Edinburgh, 1869. 

Diseases of the Ovaries. T. Spencer Wells, F.R.C.S. London, 1872. 

Ovarian Tumors. Dr. Peaslee. New York, 1872. 

Diagnosis of Ovarian Tumors. Dr. Atlee. Philadelphia, 1873. 

Lectures on Diseases of Women. Dr. A thill. Reprint, 1873. 

Puerperal Diseases. Dr. Fordyce Barker. New York, 1879. 

Diseases of Women. Dr. Barnes. Reprint, 1874. 

Gardner on Sterility. New York, 1856. 

Hey on Puerperal Fever. Reprint, 181 7. 

Essays on Puerperal Fever. Various authors. London, 1849. 

Walshe on Cancer. London, 1846. 

Diseases of Women. Prof. Thomas, Philadelphia, 1869. 

The Utricular Glands of the Uterus. Prof. Ercolani. Boston, 1880. 



Xll WORKS CONSULTED. 

Diseases of Female Sexual Organs. (Ziemssen's Cyc, Vol, X.). Prof. Schroeder, 

New York, 1876. 
Minor Surgical Gynecology. Dr. Paul F. Munde. New York, 1880. 
Winckel on Childbed Diseases. Philadelphia, 1876. 
Practical Gynecology. Dr. Hey wood Smith. Reprint, 1878. 
Diseases of the Bladder and Urethra in Women. Dr. Skene. New York, 1878. 
Diseases of Women. Dr. Galabin. Reprint, 1879. 
Lessons in Gynecology. Dr. Goodell. Philadelphia, 1879. 
Principles and Practice of Gynecology. Dr. Emmet. Philadelphia, 1879. 
Diseases of Women. Lawson Tait, F. R.C.S. Reprint, 1879. 
Surgery of the Female Pelvic Organs. Dr. Savage. Reprint, 1880. 
Surgical Diseases of the Genito- Urinary Organs, Drs. Van Buren and Keyes. 

New York, 1877. 
Diseases of the Rectum. Wm. Allingham, F. R.C.S. Reprint, 1880. 
Diseases of the Intestines and Peritoneum. New York, 1879. 
Venereal Diseases. Dr. Bumstead. New York, 1870. 
Baumler on Syphilis. (Ziemssen's Cyc., Vol. III.). New York, 1875. 
Examination of Urine in Disease. Dr. A. Flint, Jr. New York, 1871. 
Examination of Urine. Dr. Tyson. Philadelphia, 1878. 
Foster's Physiology. London, 1880. 
Gross' System of Surgery. 
Infant Feeding. Dr. Routh. Reprint, 1879. 
Institutes of Surgery. Sir Chas. Bell. Edinburgh, 1838. 
Surgical Observations. Dr. J. Mason Warren. Boston, 1867. 

Smellie's Midwifery. 3 vols. Edinburgh, 1784. 

Burns' Midwifery. London, 1817. 

Practical Midwifery. Dr. Gooch. Reprint, 1855. 

Collins' Midwifery. Reprint, 1841. 

Ramsbotham's Obstetrics. London, 1841. 

Researches in Obstetrics. Dr. J. Mathews Duncan. Edinburgh, 1868. 

Fecundity, Fertility, Sterility. Dr. J. M. Duncan. Edinburgh, 1867. 

Obstetrical and Gynecological Works of Sir James Simpson. Reprint, 187 1. 

Obstetric Clinic. Dr. Elliott, New York, 1868. 

Obstetric Operations. Dr. Barnes. Reprint, 1870. 

Leishman's Midwifery. Reprint, 1873. 

Schroeder' s Midwifery. New York, 1873. 

Playfair's Midwifery. Reprint, 1878. 
.Physicians and Surgeons of the United States. Philadelphia, 1878. 

Minor Gynecological Operations. J. H. Croom, M D. Edinburgh, 1879. 
iUterine and Ovarian Inflammation. Dr. E. J. Tilt. London, 1862. 

Periodicals and Pamphlets. 

British Obstetric Record. 2 vols. Manchester, 1849. 
British Medical Journal. 



WORKS CONSULTED. xiii 

Glasgow Medical Journal. 

Boston Medical and Surgical Journal. 104 vols. 

Obstetrical Journal -of Great Britain and Ireland. 

New York Journal of Obstetrics. 13 vols. 

Journal of the Gynaecological Society of Boston. 7 vols. 

Transactions of the American Gynecological Society. 5 vols. 

Transactions of the London Obstetrical Society. 22 vols. 

Report of the Columbia Hospital for Women, Washington, 1873. 

Hayward's Surgical Reports. Boston, 1855, 

London Lancet. 

New York Medical Record. 

Medical and Surgical Reports Boston City Hospital. 2 vols. 

Braithwaite's Retrospect. 

Philadelphia Medical and Surgical Reporter, 

Note-Book for Cases of Ovarian Tumors. Spencer Wells, F. R. C.S. London, 

1877. 

Three Hundred Additional Cases of Ovariotomy. Spencer Wells, F.R.C.S. 
London 1877. 

Additional Cases of Ovariotomy during Pregnancy. Spencer Wells, F.R.C.S. 
London, 1878. 

Surgery, Past, Present, and Future, Spencer Wells, F.R.C.S. London, 1877. 

Excessive Mortality after Surgical Operations. Spencer Wells, F.R.C.S. Lon- 
don, 1877. 

Suppurating Ovarian Cysts. Dr. Thos, Keith, F,R.C.S.E. Edinburgh, 1875. 

Intra-Uterine Fibroids. Dr. Marion Sims. New York, 1874. 

Surgery of the Cervix. Dr. Emmet. New York, 1869. 

Prolapsus Uteri. Dr. Emmet. New York, 1871. 

Philosophy of Uterine Disease. Dr. Emrnet. New York, 1874. 

Laceration of Cervix Uteri. Dr. Emmet. New York, 1874. 

Removal of Fibroids by Traction. Dr. Emmet. New York, 1875. 

Etiology of Uterine Flexures, Dr. Emmet. New York, 1876. 

Atresia of the Vagina. Dr. JEmmet. New York, 1878. 

New Instrument for Treatment of Suppurating Cavities, Dr. Bixby. Boston, 
1875. 

Laceration of Cervix Uteri. Dr. Goodell, Philadelphia, 1878. 

Vaginal Ovariotomy. Dr. Wing. Boston, 1876. 

Malignant Degeneration of Fibroid Tumor. Drs. Blodgett and Wing, Boston, 
1876. 

Cases of Antiseptic Ovariotomy. Dr. John Honians. Boston, 1879. 

Food as a Medicine in Uterine Fibroids. Dr. E. Cutter, New York, 1877. 

Clmical Lectures on the Diseases of Women. J. Mathews Duncan, M,D. Re- 
print, 1 88 1, 

The Hot Rectal Douche.^ Dr. James R. Chadwick. Boston, 1881. 

Obstetric and Gynecological Literature, Dr. James R. Chadwick. Boston, 1881. 



DICTIONARY. 



Agalactia, complete suppression of the lacteal secretion. 

Alopecia^ loss of hair. 

Analgesia, absence of pain. 

Blennorrhoea, inordinate discharge of mucus. 

Caducous, applied to the shedding of mucous membrane after miscarriage or 
delivery. 

Caiamenia, menstruation. 

Cholesterin^ the chief ingredient of biliary concretio? % 

Clap, gonorrhoea. 

Colpitis, inflammation of the vagina. 

Consensual pain occurs in a part not primarily diseased, but associated in func- 
tion vi^ith an organ which is diseased ; as pain in the left ovary dependent 
on disease of cervix uteri. 

Crypsorchis^ non -descent of the testicles into the scrotum. 

Deciduous^ to be thrown off, applied to the outer membrane of the foetus. 

Denidation^ exfoliation of uterine mucous membrane during menstruation. 

Diastasis^ a separation of bones from each other. 

Dysckezia^ difficult and painful defecation. 

Dysobtocia, painful ovulation. 

Dysuria, painful micturition. 

Ectropium of cervix^ eversion of lining membrane, caused by prolapsus or cica- 
trix. 

Embolism^ the blocking of an artery by a dislodged clot or vegetations. 

Endermoptosis^ small sebaceous tumors in the labia. 

Enterocele^ descent of intestine, forming a pouch in the vagina. 

Erotomania^ insanity due to excessive sexual desire. 

Galactorrhoea^ excessive secretion of milk. 

HcB7natometra^ collection of blood in the womb. 

Hermaphrodite, union of the two sexes in the same individual. 

Hydronephrosis^ dropsy of kidney. 

Hydrosalpinx, dropsy of Fallopian tube. 

Hypercsmia, "a non-inflammatory collection of blood in a part." — Trousseau. 
" A lesion of the circulation, in which the quantity of blood is preternatu- 
rally increased." — Andral, 

HypercBsthesia, greatly increased sensibility. 

Hyperinosis^ excess in amount of fibrin and serum, and deficiency of corpuscles in 
blood. 

Hyperplasia^ development of new connective tissue in excess. 



XVI DICTIONARY. 

Hystej'otomy, removal of uterus through an abdominal incision. 

Icho7'rhtE7nia^ chronic septic infection limited to individual organs. 

Indagation^ examination (applied to the genitals). 

Inopexia^ abnormal tendency to coagulation of the blood where the proportions 
are normal. 

Ischuria^ retention of urine ; sometimes applied to arrest of the secretion. 

Lientery^ passage of food through the bowels undigested soon after it has been 
swallowed. 

Litholapaxy^ removal of stone by crushing and washing out the fragments at a 
single sitting. 

Lordosis, curvature or deformity of bones. 

Marasmus^ wasting away from deficient nutrition. 

Menopause, period of life at which menstruation naturally ceases. 

Metatithvienia, effusion of blood in the tissues near the uterus ; misplaced men- 
struation. 

Multipara, a woman who has borne more than one child. 

Necrobiosis, formation of septic matter within the system by those morbid pro- 
cesses which result in disorganization. 

Nidation, thickening of uterine mucous membrane before ovulation. 

Nosocomial malaria, the hospital atmosphere, charged with exhalations from sur- 
gical patients. 

Nymphomania, insatiable desu-e for the venereal act. 

Onanism, masturbation. 

Oophorectomy, ovariotomy. 

Oophoritis, inflammation of the ovary, 

Paralbumen, a form of albumen soluble in strong boiling acetic acid. 

Parametritis, pelvic cellulitis. 

Parthenogenesis, development of an ovum without impregnation. 

Pediculated, with a narrow neck, as a polypus. 

Perimetritis, pelvic peritonitis. 

Perineorrhaphy , operation for lacerated perineum. 

Primipara, a woman who has borne only one child. 

Proctitis, inflammation of rectum and anus. 

Penitent, resisting pressure, firm. 

Salpingitis, inflammation of a Fallopian tube. 

Saprcemia, putrid intoxication. 

Sarcoma, a tumor without a capsule, feeling like placental tissue, and easily 
broken down. 

Sessile tumor, attached by a broad surface ; without a pedicle. 

Spamjnenorrhoea, scantiness of the menstrual flow. 

Span(zmia, poverty of the blood. 

SiibinvohitioTi, hypertrophy of womb, caused by arrest of absorption after delivery. 

Syphilophobia, ungrounded dread of having acquired syphilis. 

Thrombosis, coagulation in veins. 
Vtdsellum^ a toothed forceps. 



DISEASES OF WOMEN. 



CHAPTER I. 
ANATOMY OF THE GENITAL ORGANS. 

To understand the nature of a disease, and be able to rec- 
ognize it, we must first have an accurate idea of the anatomy 
of the parts involved. We must know the natural position of 
the womb before we can tell whether it is displaced or not ; 
we must be aware of its ordinary size before deciding whether 
it is enlarged or shrunken ; and it is absolutely necessary to 
a correct diagnosis of uterine disease that we should be fa- 
miliar with the sensations communicated to the finger, and 
the appearances presented to the eye by a sound organ. I 
do not propose to discuss the subject minutely. Elaborate 
treatises, numerous dissections and post-mortem examina- 
tions, are needed by the student of anatomy. The details 
which follow are intended to refresh the practitioner's mem- 
ory, by condensing into small compass some of the essential 
facts about the surgical anatomy of the female pelvic organs. 

In all examinations and operations in this region, we re- 
quire to bear in mind the peculiar curve (Cams') belonging 
to the inlet and outlet of the pelvis. We should also make 
ourselves famihar witlu certain bony "landmarks" by exer- 
cising the sense of touch on living subjects. These are, ex- 
ternally, the anterior superior spinous process of the ileum, 



1 8 DISEASES OF WOMEN. 

the spine and symphysis of the pubis, and the tuberosity of 
the ischium ; internally, the sacral promontory, the coccyx, 
and the ramii of the ischium and pubis. 

The bladder lies immediately behind the pubis, except 
when inordinately distended with urine, when it may reach 
as high as the umbilicus ; the rectum lies in the hollow of the 
sacrum and coccyx, and the uteriiSy with its appendages, 
between the two. The ovaries are attached to the posterior 
folds of the broad ligaments, one on each side, on a level with 
the fundus uteri, in front of the rectum. The vagina leads 
up to the neck of the womb, and has lodged in its upper wall 
the urethra, commencing at the meatus urinarius. The vulva 
includes the mons veneris, the labia majora and minora, the 
clitoris, and the hymen. 

The mammaiy gla?ids are so intimately connected with the 
reproductive organs that their anatomy will be briefly de- 
scribed. All these organs should be studied separately, and 
in their relations to each other. 



THE FEMALE BLADDER 

is made up principally of two coats — mucous and muscular. 
The peritoneum only covers the fundus, and a small surface 
next the uterus. Those parts of the bladder in contact with 
the pubis and the anterior vaginal wall have no serous 
covering. In the young child and the aged woman the 
longest diameter is the vertical ; during adult life the trans- 
verse diameter is the longest. Its ordinary capacity is about 
one pint; although, when distended, it is capable of holding 
six quarts. The openings into it are three, namely, the two 
ureters and the urethra. These represent a triangular space, 
of which the two ureters constitute the base and the urethra 
the apex ; and the distance from each opening is about one 
inch. These facts require to be recollected in making an arti- 
ficial fistula for the relief of cystitis, or in removing a stone 
from the bladder. The ureters pierce the bladder obliquely. 



ANATOMY OF THE GENITAL ORGANS. 1 9 

running for an inch between the muscular and mucous coats. 
The mucous membrane of the bladder does not possess much 
absorbent power unless abraded. The average amount of 
urine passed by a healthy woman in twenty-four hours is 
forty ounces. After long-standing cystitis the capacity of the 
bladder may be reduced to a spoonful or two, and the walls 
(principally the muscular coat) become much thickened. 
Very limpid urine (hysterical-urine) acts as an irritant to the 
bladder, and so does that which is highly concentrated. 



URETHRA. 

The female urethra is a short, wide canal, less than two 
inches long, directed backward and upward to the neck of 
the bladder. It lies about an inch below the glans clitoridis, 
and immediately above the vaginal entrance, being, as it 
were, hollowed out of the upper vaginal wall. Its diameter is 
about one-fourth of an inch, and it is capable of being rapidly 
distended. Its mucous coat contains a large amount of 
elastic tissue. The female urethra pierces the triangular liga- 
ment, as in the male. 

Hozv to introduce a catheter. — The surgeon is frequently 
called upon to pass a catheter along this canal, and to do it 
adroitly, without exposing the patient, or giving her pain, is 
one of those minor operations which often makes or mars a' 
young doctor's reputation. • Most of the silver instruments 
sold in stores are faulty in size and shape. I seldom use a 
metallic female catheter ; a flexible male catheter (No. 6 or 
7) is much to be preferred. For convenience of carriage in a 
pocket case it may be cut in two, using the distal piece ; and 
it is a good plan to attach a few inches of small rubber tubing 
over the outer end, which serves to carry the urine into a 
basin. If a silver catheter is preferred, a flattened or ovoid 
one, of small calibre, should be selected. 

The patient lies on her back, with her knees drawn up and 
separated. The catheter is warmed, smeared with vaseline, 



20 DISEASES OF WOMEN. . 

and held in the surgeon's hand Hke a pen. It rests on the 
middle finger, which should project a little beyond the point of 
the instrument ; the forefinger slightly presses the vestibule 
downward, and the catheter, being depressed, readily slips 
into the urethra. The surgeon will know that he has succeed- 
ed, by passing his middle finger into the vagina and feeling 
the instrument through the upper wall, but not in the vagina. 

In women who have borne children the meatus lies lower 
down, and may even sometimes be found under the arch of 
the pubis. The meatus also lies low in young girls. During 
the latter months of gestation, and during labor, only a soft, 
flexible catheter should be used, passing it close to the pubis, 
that is, in a nearly perpendicular direction. In all cases the 
utmost gentleness and delicacy of manipulation must be em- 
ployed. Force — by which I mean perceptible resistance, or 
hard pushing — is never justifiable. I have occasionally met 
with a spasmodic contraction of the urethra, which prevented 
catheterism ; in such cases we must wait till the parts be- 
come relaxed, or give ether. That the urethra and contigu- 
ous parts possess considerable muscular power, is proved by 
the circumstance that the catheter may be expelled as it is 
lightly supported in the surgeon's hand. 

Occasionally, when urine cannot be voided in the ordinary 
position, the patient may succeed when lying on her face ; 
and there are some cases where it is most easily voided in 
the erect posture. 

The urethra may be safely dilated to the extent of admit- 
ting a slim forefinger to explore the bladder. Dr. Churchill 
relates a case in which the hymen was *' rigid and persistent, 
the vaginal orifice very small, but the urethra extremely 
dilated, and I ascertained, beyond all doubt, that intercourse 
always took place through the urethra." ^ Dr. H. R. Storer 
details a remarkable case,^ in which a Hodge's open-lever pes- 

' Churchill on Diseases of Women, p. 84, 1857. 
- New York Medical Record for July 15, 1868. 



ANATOMY OF THE GENITAL ORGANS. 21 

sary was unintentionally introduced into the bladder through 
the urethra, by a physician. Dr. Storer removed it success- 
fully, without incision, by dilating the urethra. The patient, 
a young unmarried lady, soon regained complete control of 
the vesical sphincter. He also refers to another case/ Pro- 
fessor Byford gives details of two cases which occurred in his 
practice/ and Dr. Edwards, of Lancaster, Ohio, relates the 
particulars of another. In all, five cases where an open-lever 
pessary was introduced into the bladder instead of the vagina. 



VAGINA. 

The vagina is a collapsed tube, about five Inches long, nar- 
rowest at the entrance, where it is surrounded by a sphinc- 
ter muscle ; and, in women who have borne children, a cavity 
near the upper part, the rest of the canal being in contact 
antero-posteriorly. The bulb occupies the upper vaginal 
wall near the entrance; it varies in size even in the same 
person, undergoing at certain times a kind of erection. This 
part has sometimes been mistaken for the womb, simulating 
prolapsus. The uterine neck dips down into the vagina about 
three-fourths of an inch. The vaginal attachment is at the 
middle of the cervix uteri, so that we have an infra- and a 
supra-vaginal portion of the neck. 

The glands which furnish mucus occur most abundantly 
near the vaginal entrance. The odor varies In different per- 
sons. In some It is scarcely perceptible, while in others, 
equally healthy, it may be positively nauseous. The vulvo- 
vaginal glands, each about the size of an almond, are situated 
near the lower part of the vulva, and, under the Influence of 
nervous excitation, furnish a copious secretion to lubricate 
the entrance. Occasionally one of the ducts becomes oc- 
cluded, and the retained secretion has even been mistaken 



' Gynecological Journal, August, 1870. 

2 Chicago Medical Examiner, December, 1869. 



22 DISEASES OF WOMEN. 

for a malignant tumor. Vaginal mucus Is strongly acid ; 
that portion secreted by the vulvo-vaglnal glands Is trans- 
parent and sticky, and Is discharged abundantly during sex- 
ual excitement, and also In natural labor ; while the portion 
secreted by the sebaceous glands in the upper part of the va- 
gina Is of a creamy consistence. The mucous membrane Is 
covered with a squamous epithelium ; and, except at the 
vulva and upper part, no glands are found In its structure. 

The vagina is a curved canal, the posterior wall of which 
Is longer than the anterior wall, so that, In making a vaginal 
examination, our finger reaches the anterior pouch more 
readily than the posterior one (Douglas' sac). The whole 
canal has been likened to a flexible tube shortened anteriorly 
by a cord passed from end to end through one of its sides. 
This arrangement would corrugate the shortened side ; and, 
In nature, we find the anterior wall not only shortened but 
much puckered. The mucous membrane, accordingly, has 
numerous oblique rugse ; but the common notion that these 
are Intended for aiding distention during labor seems to me 
to be erroneous. 

The vaginal entrance Is nearer the symphysis pubis than the 
coccyx. The posterior or lower part is called \h^ fotircJiette, 
and this is often partially torn during the passage of the child's 
head or shoulders In labor. All three coats — mucous, mus- 
cular, and membranous — are closely united, and the combined 
walls are remarkable for their elasticity. The vagina serves 
for copulation, and for the transmission of whatever may be 
expelled from the w^omb. The vagina may be partially closed 
or entirely absent. 

UTERUS. 

The uterus, matrix, or womb, Is a stout muscular bag, 
shaped like a flattened pear, nearly three Inches long, two 
inches wide at the upper part, and one Inch thick. It lies 
between the bladder and rectum ; the fundus upward and 



ANATOMY OF THE GENITAL ORGANS. 



23 



directed forward. The womb has three openings, namely, 
two in the upper angles for receiving ova and transmitting 
semen — the termination of the Fallopian tubes — and the os 
at the lower part of the neck, opening into the vagina. The 
uterine termination of the Fallopian tubes enter obliquely ; 




Fig. I.— Section of Pelvic Organs. (After Junker.) 



they are only large enough to receive a bristle, and are gen- 
erally filled with mucus. The distal extremities, attached to 
each ovary, are trumpet-shaped, and of much larger calibre. 
The virgin os" uteri is a slit, In general, large enough to allow 
the passage of a No. 6 bougie. 

The uterus Is divisible into the body or upper part, which 
receives the ovum, nourishes it during gestation, and finally 
expels the child during labor ; and the Jieck or lower part. 



24 DISEASES OF WOMEN. 

bounded above by the internal os. The circular fibres of the 
body are continued into the neck through its whole extent, 
and form a sort of double sphincter at the internal and exter- 
nal OS. In applying tannin, or any strong astringent, to 
the inner cervical surface, this contractile power is demon- 
strated. The whole organ is more convex posteriorly than 
in front ; and as the broad ligaments are attached on a level 
with the anterior surface, the sensation of roundness can be 
felt by means of two fingers of the left hand in the rectum, 
while pressing down the uterus externally with the right 
hand. 

The uterine cavity is lined by a thick mucous membrane 
which is thicker in the cervix than in the corpus. There is 
no submucous tissue between the muscular and mucous lay- 
ers, so that it is practically impossible to separate the two 
distinctly, the muscular fibres and mucous tissue being par- 
tially interwoven. The peritoneal coat covers the entire pos- 
terior surface of the womb, dipping down even below the 
level of the posterior lip ; but on the anterior surface it 
abruptly terminates on a level with the internal os, and is 
reflected upon the bladder. On this account the connection 
between the bladder and uterus is much more intimate than 
that between the rectum and uterus ; a layer of cellular 
tissue binds the neck of the bladder closely to the cervix 
uteri, and any change of position, such as occurs in prolapsus, 
affects the bladder more than it does the rectum. Unless 
when distended by menstrual fluid, clots, tumors, or a foetus, 
the uterine walls are normally in contact. The cavity in 
a virgin uterus is only large enough to contain a split al- 
mond. The mucous membrane lining the cervix is corru- 
gated, and is called arbor vitce. On account of these rugae, 
it is sometimes easier to pass a full-sized sound than a very 
small one, the latter being more apt to be caught in a fold, 
as occasionally happens in male catheterism. The cavity 
is sHghtly curved, so the sound should have a corresponding 
curve. 



ANATOMY OF THE GENITAL ORGANS. ■ 2$ 

Uterine mucus has an alkaline reaction. That portion 
which comes from the body is creamy in appearance, while 
the mucus secreted in the cervix is transparent and viscid, 
like white of egg. 

The epithelium of the body, and as far as the middle of 
the neck, is cylindrical, with fine cilia ; but the cilia do not 
appear till puberty. The lower third of the neck is lined 
with pavement epithelium. 

The uterus is supplied with blood through the ovarian and 
uterine arteries. The cervix is not as vascular as the corpus, 
but the 'walls of the blood-vessels are very thick. During 
pregnancy the body is channelled out with large veins or 
sinuses, consisting of the inner venous coat surrounded with 
non-striated muscular fibres. The uterus is also 'supplied 
with lymphatic vessels, distinguishable during pregnancy. 
The nervous supply is principally derived from the sympa- 
thetic system, and is most abundant at the level of the inter- 
nal OS. The hypogastric and renal plexuses, with a few 
branches from the sacral nerves, join together between the 
broad ligaments, close to the arteries, and send off filaments 
which penetrate the uterine walls. In health the non -gravid 
uterus is not very sensitive, and there can be no doubt that 
its nerves are but few In number ; neither do they increase 
much in size during pregnancy. 

The weight of the uterus, at puberty. Is about one and a 
half ounces ; at full term of gestation, nearly two pounds ; 
after involution, two ounces ; and In old age, one ounce. The 
uterus may be present in a merely rudimentary form, or it 
may be entirely absent. 

The uterine ligaments are eight In number, four on each 
side. They are the broad, the round, the utero-sacral, and the 
lUero-vesical ligaments. The broad ligaments consist of a 
double fold of peritoneum, with patches of muscular fibres in- 
"terposed, attached to tjie anterior surface of the womb at each 
side, and also to the sides of the pelvis. The upper border 
is formed by the Fallopian tubes, which, with the ovaries and 



26 DISEASES OF WOMEN. 

their ligaments posteriorly, and the round ligaments in front 
constitute the ala vespertilionis, or bat's-wing. These liga- 
ments offer no resistance to anterior or posterior displace- 
ments, and scarcely any obstacle to prolapsus. The round 
ligaments, each about four inches long, are principally com- 
posed of muscular tissue. They arise by tendinous filaments 
near the symphysis pubis, and are inserted into the fundus 
uteri anteriorly. On account of the numerous muscular fibres 
present, it seems probable that their principal use is to draw 
the fundus forward during copulation, thus lengthening the 
vagina. If they resist displacement at all, it must be by pre- 
venting retroversion when the bladder is enormously dis- 
tended. The utero-sacral ligaments are composed of peri- 
toneal folds, inclosing smooth muscular fibres. They spring 
from the lower part of the uterine body, and are attached to 
the outer sides of the sacrum, leaving a pouch between them 
called Douglas' sac. These ligaments serve to prevent pro- 
lapsus and anteversion. In the upright posture the womb 
naturally leans forward, and the utero-sacral ligaments keep 
it from pressing on the bladder. The utero-vesical ligaments 
are only rudimentary. They consist of peritoneal folds, in- 
closing fibrous tissue, and reach from opposite the junction of 
the body with the neck, on each side, to the corresponding 
sides of the bladder, forming between them a small anterior 
pouch. 

In the virgin uterus the fundus Is level ; after delivery It Is 
convex. Except during pregnancy, or when enlarged by 
abnormal growths, the womb cannot be readily felt above the 
pubis. In more than fifty per cent, of the married women I 
have examined, the uterus lay obliquely In the pelvis, the 
fundus a little to the left side, and the os pointing to the right 
groin. Other observers give even a larger proportion in 
whom the fundus was tilted to the le-ft side. Normally, the 
uterus is mobile; and Its position is constantly subject to' 
change, as the bladder and rectum are full or empty. 



ANATOMY OF THE GENITAL ORGANS. - 2^ 

OVARIES, 

The two ovaries are really the most important of the female 
sexual organs, being essential to the function of reproduction. 
Soon after puberty they attain their complete development, 
each being then about the size of a large almond, with a 
smooth surface, and weighing about eighty-hve grains. At 
the menopause, the ovaries present a fissured, lean appear- 
ance, from the monthly escape of ova, so that they are much 
reduced in size, and in elderly women the weight does not 
often exceed forty grains. 

At each menstrual period the ovaries increase in bulk and 
vascularity ; they become about double their usual size. 
Even when menstruation is not painful, the ovaries at that 
period are tender on pressure. This fact should be recol- 
lected in forming a diagnosis. 

The left ovary rests on the rectum, and can usually be felt 
more readily than the right one. It may be palpated be- 
tween the left index finger in the vagina and the right hand 
outside. To examine the right ovary, pass the right index 
finger into the vagina, and press with the left hand on the 
abdomen. In stout women it is often difficult to detect either. 
It is almost useless to examine by the rectum. Each ovary 
is imbedded, as it were, in the posterior fold of the broad 
ligament, lying behind the Fallopian tube ; but it is not cov- 
ered by peritoneum, as was at one time supposed. The peri- 
toneum ends abruptly, a peculiar mucous epithelium taking 
its pla:e. Each ovary is attached by its internal border to 
the uterus by means of the ovarian ligament, a round cord, 
about an inch long, containing muscular fibres. The right 
ovarian ligament is longer than the left. 

Each ovary contains from ten to twenty Graafian follicles 
or ovisacs, placed near the surface ; and the rest of the organ 
is principally made up of microscopic ova. The ovary is 
convex on its posterior surface ; its lower border, along which 
the supply of blood reaches it, is straight ; its upper border 



28 



DISEASES OF WOMEN. 



is nearly semicircular. It is covered by a stout tunic (tu- 
nica albuginea) and an internal vascular layer which ramifies 
through its substance. The arterial supply comes directly 
from the aorta, and the same artery also sends a branch to 
the uterus. 

The scar left after the escape of an ovum is called corpus 
liiteunt, and was at one time supposed to be positive evidence 
of previous pregnancy ; but this conclusion is no longer tena- 
ble. Corporea lutea formed after conception takes place are 
larger and continue longer than those which result from the 
escape of an unimpregnated ovum. 




Fig. 2. — Genital Organs — Perpendicular View, (After Savage.) 



In rare cases a woman may have three ovaries. Grohe 
mentions such a case in one who had borne children. It is 
not impossible that ova and ovisacs may be dispersed in 
groups between the layers of the broad ligaments ; and such 
anomalies may account for the continuance of menstruation 
after double ovariotomy. 



ANATOMY OF THE GENITAL ORGANS. 29 



THE FALLOPIAN TUBES, 

or oviducts, each about four inches long, are of very small 
calibre at the uterine end (only sufficient to admit a hog's 
bristle), become much wider at the distal end (large enough 
to admit a Simpson's uterine sound), and terminate in fim- 
briae or fringes which have received the fanciful name of 
morsics diaboli. One of these fringes is permanently at- 
tached to the ovary ; while, at certain times, the whole fim- 
briated extremity embraces the ovary, and receives an ovum 
to convey it to the womb. The Fallopian tubes are really 
the excretory ducts of the ovaries ; but, as Dr. Barnes says, 
they differ from all other excretory ducts in being detached 
from their glands, and they furnish the only example in the 
human body of direct communication between a mucous and 
a serous surface. 

These tubes are somewhat tortuous, firm to the touch, like 
the spermatic cord, and are composed of three coats — serous, 
muscular, and mucous. The peritoneal coat only covers the 
tube for three-fourths of its circumference ; the muscular coat 
gives the tube its density ; and the mucous coat, with numer- 
ous longitudinal folds, is provided with a ciliated epithelium 
directed toward the uterus. These tubes are not furnished 
with valves. Sterility would necessarily follow from occlusion 
of both tubes. It sometimes happens that the ovum is ar- 
rested on its way to the womb while in the Fallopian tube, 
and, growing for a time, constitutes tubal gestation. 



HYMEN. 

The hymen is a fold of mucous membrane, usually thin 
and easily ruptured, which in early virginity partially closes 
the vulvar orifice. It is often of a crescentric shape, and 
thicker at the sides where it is attached. At one time its 
presence was reckoned as a proof of virginity, but this idea 
has long been exploded. I have seen a well-formed hymen 



30 DISEASES OF WOMEN. 

in a young prostitute ; and there can be no doubt that many- 
causes besides sexual intercourse bring about its destruction. 
In a female infant the hymen only exists in a rudimentary 
form. In some young women it never becomes fully de- 
veloped, and in many others its growth is arrested after 
attacks of measles or scarlet fever. In a few rare cases the 
hymen has been found fully formed and imperforate in new- 
born infants. When the membrane remains imperforate till 
puberty, and the menstrual blood necessarily imprisoned, the 
vagina, uterus, and Fallopian tubes may become successively 
dilated, and a surgical operation be required. 

CLITORIS. 

This is a rudimentary erectile organ, analogous to the cor- 
pora cavernosa of the penis, terminating in a small imper- 
forate glans. It is attached to the pubis, and is generally 
concealed by the nymphae. The smooth, triangular space im- 
mediately below it is called the vestibule. The glans clitoridis 
is very sensitive, and subject to enlargement from syphilis, 
cancer, etc. When congenitaliy hypertrophied, doubts about 
the sex are apt to arise. The late J. Baker Brown, of Lon- 
don, several times removed the entire organ (clitorodectomy) 
for nymphomania and masturbation ; but his example has sel- 
dom been imitated, and the success of such an operation is 
more than doubtful. Dr. Henry O. Marcy, of Boston, also 
operated recently (1881) with, at least, partial success. 

MAMMARY GLANDS. 

These are accessory organs for the secretion of milk, situ- 
ated over the pectoralis major muscle, from which they are 
separated by a layer of fascia. The nipple^ placed in the 
centre of the gland, lies opposite the fourth rib, and is sur- 
rounded by a rose-pink ring, the areola, from which project 
several small tubercles. The areola and tubercles undergo 



ANATOMY OF THE GENITAL ORGANS. 3 1 

certain changes in early pregnancy, more especially in primi- 
pacae. The pink color becomes brown or almost black, and 
the tubercles grow larger. This change of color never en- 
tirely disappears, although it partially fades after delivery. 
The mammae exist in men in a rudimentary state. Cases 
are on record where they have become developed after hy- 
pertrophy of the testes, and abundance of milk secreted. 



CHAPTER II. 
INSTRUMENTS AND HOW TO USE THEM. 

A SPECIALIST, who devotes his entire time to gynecology, 
may require a large assortment of instruments ; a general 
practitioner only needs a few to begin with, and, of course, 
may add to his stock as occasion demands. Many a surgi- 
cal "omnibus case" contains more than one instrument 
which, during a busy practice of more than twenty years, 
has never been used. The following list contains nothing 
superfluous :^ 

Cusco's speculum, small size. 

Sims' speculum. 

Uterine sound, soft copper, silver plated. 

Silver probe, with handle. 

Hard rubber syringe, nozzle four inches long. 

Pinkham's uterine scarificator. 

Uterine forceps, straight. 

Sponge holder. 

Tenaculum. 

Applicators. 

Scissors, long, stout, and curved on the flat. 

Morocco case for four small vials, containing carbolic acid, 
iodide of phenol, bromine, and tannin. 

As a matter of convenience, the following may be added : 

^ Messrs. Codman & ShurtlefT, No. 13 Tremont Street, Boston, can furnish the 
first set of instruments, in a suitable case or bag, for $35, or both sets in one bag 
for $70. 



INSTRUMENTS AND HOW TO USE THEM. 33 

Fergusson's speculum (glass or celluloid), two sizes. 

Neugebauer's speculum (one set). 

Recamier's or Sims' curette. 

Whalebone sound. 

Glass pipette. 

Atlee's concealed knife. 

Cauterizing irons. 

EUincrer's uterine dilator. 

o 

A common satchel, twelve inches long by eight inches 
deep, fitted with pockets, is convenient for carrying the 
necessary instruments and medicines. A supply of fine 
wool or absorbent cotton is indispensable ; also a small bottle 
of pure glycerine. 

MODE OF EXAMINATION. 
Whether for purposes of diagnosis or treatment, a stout 
kitchen table, three inches lower at the end where the patient's 




Tig. 3. — Chadwick's Office Table. 

head lies, is preferable to a bed. Cover the table with a 
folded " comforter," place a pillow at the upper end, and you 
3 



34 DISEASES OF WOMEN. 

have an arrangement which can scarcely be improved upon. 
The table should be placed opposite a window with the lower 
sash covered. Dr. Chadwick, of Boston, has invented an ex- 
cellent table for office use. 

The dorsal decubitus is the best. With the aid of a chair 
the patient sits down on the prepared table, close to the lower 
end ; she then lies down on her back, her feet are drawn up, 
and rest on the edge of the table ; she is covered with a sheet, 
and everything is ready for an examination. 

Before sitting down to examine a patient, the surgeon 
should always wash his hands in warm water ; this insures 
cleanliness, softness, and greater tactile sensibility. He may 
then lubricate the fore and middle fingers of his left hand 
with moistened soap, and gently introduce them into the 
vagina. At the same time his right hand makes steady pres- 
sure over the pubis. This is called bimanual palpation. 
During the examination he ascertains the position, size, and 
condition of the womb; whether it is tender, inflamed, or 
ulcerated ; whether a polypus, or other tumor, projects into 
the vagina ; the state of the rectum, whether emxpty or full 
of fseces ; and many other points only to be learned by ex- 
perience. 

For most purposes, as already remarked, the dorsal decu- 
bitus is the best. Occasionally, however, the lateral position 
— on the left side — is preferable ; and, if we use a Sims' 
speculum, it is the best. Dr. Sims says : " The thighs are to 
be flexed at about right angles with the pelvis, the right 
being drawn up a little more than the left. The left arm is 
thrown behind across the back, and the chest rotated for- 
ward, bringing the sternum very nearly in contact with the 
table, while the spine is fully extended, with the head resting 
on the left parietal bone. The position must simulate that 
on the knees as much as possible." The patient's clothes 
should be quite loose, the head and shoulders low. 



INSTRUMENTS AND HOW TO USE THEM. " 35 

INSERTION OF SPECULUM. 
Cusco's speculum is the one commonly used. The instru- 
ment has been lying in a basin of warm water, and is first 
lubricated with softened Castile soap. Gently separate the 




Fig. 4, — Cusco's Speculum. 

labia, and introduce the closed speculum, with its narrow diam- 
eter parallel to the ostium vaginae, the handles being di- 
rected toward the patient's left thigh. After it is fairly in- 
serted (about one inch) turn the handles downward, which 
brings the wide diameter across the entrance, and complete 
the insertion. The previous digital examination informs us 
where the cervix is located, and enables us to guide the in- 
strument correctly ; but, as a general rule, the distal end 
should be depressed ; in other words, direct the speculum 
downward and backward. It should be inserted as far as 
necessary before opening the blades. If properly done, the cer- 
vix is fully exposed to view, the upper blade passing up into 
the anterior, and the lower one into the posterior cul-de-sac. 
If a cylindrical speculum be used, open the labia as before, 
and press the projecting part of the bevelled end against the 
fourchette, so as to retract the perineum. A gentle rotary 
motion, with slight pressure downward and backward, will 



36 



DISEASES OF WOMEN. 



insure Its entrance. In all cases, examine first with the finger 
to ascertain the position of the cervix. The instrument should 
be warm and well lubricated, and in some cases its insertion 




Fig. 5. — Fergusson's Speculum. 



will be facilitated by smearing the vulva with vaseline. A cel- 
luloid speculum of the same pattern is more durable. Tinct- 
ure of camphor or strong alcohol injure it. 

Sims' speculum requires the services of an assistant, who, 
" standing at her back, pulls up the right side of the nates 




Fig. 6. — Sims' Speculum, 



Fig. 7.— Neugebauer Speculum. 



With the left hand, when the surgeon introduces the specu- 
lum^ [carrying his finger in front till it has passed beyond the 
cervix], elevates the perineum, and gives the instrument into 
the right hand of the assistant, who holds it firmly in the de- 
sired position." This speculum is the best for use in surgical 



INSTRUMENTS AND HOW TO USE THEM. 



37 



Operations. It may be improvised by bending a long-handled 
pewter spoon, or a flat strip of block tin. 

The Neugebauer speculum possesses certain advantages. 
It is easier cleaned and kept clean than any other self-re- 
taining speculum. The four blades constitute three specula 
of graded sizes. It is easily introduced, and gives an excel- 
lent view of the cervix. By boring holes in the handles and 




Neugebauer Speculum. 



fastening two blades together with a pin and nut, two pieces 
can be readily converted into a Sims' speculum. 



CLEANSING THE PARTS. 



Syringe out thoroughly with lukewarm water, and, if ne- 
cessary, wipe the parts with cotton held in the split probang. 
If a glairy discharge is issuing from the os uteri, pass in a 
probe covered with a little cotton, not higher than the inter- 




nal OS, so as to remove the secretion. This often proves a 
tedious part of the process, for the albuminous-looking secre 



DISEASES OF WOMEN. 



[ 



tion is very sticky, and difficult to remove. The wire found 
in flexible catheters, shortened and roughened at the distal 
end, makes a good applicator. Some practitioners have 
expressed a fear th^t the cotton might slip off. A very little 

practice will easily ena- 
ble one to avoid this 
accident. If properly 
put on, the difficulty lies 
rather in removing the 
cotton after it has been 
used ; it adheres so ten- 
aciously that we have to 
cut it off with knife or 
scissors. The following 
is my method. Spread 
the cotton in a thin layer 
between your left thumb 
and forefinger ; dip the 
applicator into water and 
lay it on the cotton ; 
then rapidly twirl the 

I applicator so as to twist 

. the cotton around it, be- 

fi ginning at the rough ex- 
, , H tremity and ending an 

|9 gj inch above it. The 

I 1^ layer of cotton should be 

IB [ ^ progressively thinner to- 

il IH ward the proximal end. 

IP IB Prof. Byford recom- 

mends that the cotton be 
tied on with thread ; but 
this way, besides being clumsy, is not as secure. The whale- 
bone applicator should terminate in a small olive-shaped bulb. 
The uterine sound may be used as an applicator, if nothing bet- 
ter is at hand. Lente's silver probe makes a good applicator. 



Fig. io. — Split 
Probane. 



Fig. II. — Simpson's 
Uterine Sound. 



Fig. 12. — Lente': 
Silver Probe. 



INSTRUMENTS AND HOW TO USE THEM. 39 

APPLICATION OF REMEDIES. 

Carbolic acid, iodide of phenol, nitric acid, chromic acid, 
or any other liquid preparation, may be applied to the outer 
surface of the cervix by means of a camel's-hair pencil or a 
glass rod. When a liquid remedy is indicated for the cavity 
of the womb, the best way is to make a small swab of cotton, 
as already described, soak this in the liquid, and pass it to 
the inner os, or to the fundus if necessary. Many serious 
accidents have happened from uterine injections. They are 
exceedingly apt to bring on uterine colic ; and in some re- 
corded cases the fluid injected has passed into the peritoneal 
cavity, through the Fallopian tubes, and resulted in peritonitis 
and death. 

A glass pipette, seven inches long and one-fourth inch 
diameter, drawn to a bulbous point at one end, with a small 
rubber bulb at the other, is a convenient instrument for ap- 



FiG. 13.— Glass Pipette, 

plying liquids to the body of the womb. Draw in the medi- 
cine by squeezing the bulb while the point is immersed. 
Eject all you do not mean to use, Avrap a little absorbent cot- 
ton around the distal end, pass the pipette up to the fundus, 
slowly press the bulb, and withdraw the instrument. Not 
more than four drops should be used at a time. This is ab- 
sorbed by the cotton, and wiped on the lining membrane. 

In applying strong acids (with a glass rod), a layer of cot- 
ton full of dry sodium carbonate should be placed in the pos- 
terior cul-de-sac, to neutralize any superfluous acid. If caustic 
potash (or soda) is used, a piece of cotton soaked in vinegar 
should occupy the same position, the object in view being iden- 
tical — to prevent injury to the vagina. A pledget of cotton 
may be placed underneath the cervix when iodide of phenol is 
used. The milder remedies do not require these precautions. 



40 DISEASES OF WOMEN. 

REMEDIES APPLIED BY THE PATIENT. 

These are principally two, namely, vaginal injections of 
hot water, and cotton (or woollen) pessaries soaked in gly- 
cerine. 

The best way to give injections is by means of the vaginal 
douche, an arrangement similar to the fountain syringe, in 
which a small wooden pail takes the place of the rubber bag. 
Bore a hole in a pail close to the bottom and insert one inch 
of stout glass tubing. To this, six feet of rubber tubing is 
attached, terminating in a hard-rubber nozzle, four inches 
long, with a bulb at the distal end pierced with side-holes. 




Fig. 14.— Vaginal Douche. 

but no central aperture. The pail, full of hot water (104° to 
108° F.), is placed on a table or bureau ; the patient lies on a 
lounge, her hips higher than her shoulders, and a rubber 
blanket so arranged as to carry off the water into a tub ; she 
pinches the rubber tube with one hand, and inserts the hard- 
rubber tube into the vagina with the other, always recollect- 
ing to point dowiizvard with the tube so as to avoid entering 
the cervical canal. On slacking the pressure, the water flows 
in a continuous stream, and may be applied for any length of 



INSTRUMENTS AND KOW TO USE THEM. . 4 1 

time desired. Not less than one gallon should be used at a 
sitting, and treble that quantity, or more, may be used with 
advantage. 

The largest size fountain syringe can be used instead of a 
pail ; or the common enema syringe may be employed. 
The objections to the latter are, that it is a laborious pro- 
cess to pump so large a quantity of water, and the patient 
is tempted to do with less than is really necessary ; and the 
intermittent character of the process (each jet acting as a sort 
of blow) is not as beneficial as a continuous stream. Dr. 
Emmet prefers the stream from a Davidson syringe because 
it is intermittent ; but he uses the continuous current in the 
Woman's Hospital. 

The cotton (or woollen) pessary is another remedy which 
the patient can safely apply herself. It consists of a small 
roll of absorbent cotton or wool, soaked in lukewarm water, 
the water squeezed out, and its place supplied with glycerine, 
gradually introduced by holding the pessary between the 
forefinger and thumb of the left hand, pouring on a teaspoon- 
ful, and patting it in with the tips of two fingers of the right 
hand until a sufficiency has been taken up. Then tie a piece 
of fime twine around the cotton, expand the labia with two 
fingers, and slip the pessary between them, pressing it down- 
ward behind the uterine neck. It can be removed by pulling 
the string, which is left hanging out of the vagina. As a 
general rule, it should not be left in longer than twelve hours. 
The patient should be told that a watery flow will follow its 
use. It relieves inflammation, supports the womb, and acts 
as a disinfectant. The profession are indebted to Dr. Sims 
for this excellent remedy. In most cases fine wool is prefer- 
able to cotton, being more elastic. 

Professor Byford recommends the use of small linen bags, 
like the finger of a glove, filled with alum, iron sulphate, or 
other astringent, to be inserted by the patient herself. 



CHAPTER III. 
VULVITIS, VAGINITIS, PRURITUS, LEUCORRHCEA. 

VULVITIS 

occurs more frequently in childhood than at other periods. 
It consists in acute inflammation of the vulva, the parts being 
red, swollen, and bathed in a mixture of pus and mucus. 
The mucous membrane is most frequently affected, but the 
disease may involve all the tissues. In adults the disease is 
apt to commence in the numerous follicles and sebaceous 
glands which stud the parts affected. M. Huguier points 
out the similarity between the anatomical structures of the 
vulva and the face, resulting in a corresponding similarity of 
diseases. Affections of the skin, such as prurigo, eczema, 
acne, and erysipelas, are also liable to attack the vulva. Vul- 
vitis sometimes results from awkward attempts at intercourse 
in the newly-married. When young girls are affected, sus- 
picion of attempts at sexual intercourse, by monomaniacs, is 
often excited — in most cases without foundation. Vulvitis 
occasionally forms one of the sequelae of scarlatina. 

The vulvo-vaginal gland on one side may be involved in 
the inflammation, and its duct occluded, giving rise to a fluc- 
tuating tumor, sometimes as large as a hazel-nut. 

Treatment. — Rest in bed, lukewarm sitz baths, at least 
twice a day, pledgets of absorbent cotton saturated with gly- 
cerine and laudanum placed between the labia, and mild 
saline cathartics (sodium phosphate), constitute the main 
items of treatment. The diet in most cases should be gruel, 
milk, beef-tea, or soup. When a specific origin (gonorrhoea) 



VULVITIS, VAGINITIS, PRURITUS, LEUCORRHOEA. 43 

is suspected, special care must be taken to avoid infection. A 
weak, warm, aqueous solution of iodine maybe used as a dis- 
infectant, and potassium iodide given internally. Abscesses 
near the vulvo-vaginal gland should be freely opened, and 
the surface swabbed with strong tincture of iodine. 



VAGINITIS, 

sometimes called colpitis or blennorrhcea, may be of specific 
origin, as in gonorrhoea, or non-specific, constituting simple 
inflammation of the vaginal mucous membrane. Both of 
these forms may be either acute or chronic. It is difficult, if 
not impossible, to diagnosticate between the specific and 
simple forms. That resulting from gonorrhoeal infection 
generally spreads to the urethra, and the mucous membrane 
at the upper part of the vagina is intensely red ; the muco- 
purulent secretion is also more abundant, and often tinged 
with blood. We must be governed mainly by the history of 
the case and the moral status oi the patient in deciding 
whether the affection is specific or not. Simple vaginitis 
most frequently results from inflammation of the cervix or 
from endometritis, the acrid discharge irritating and inflam- 
ing the parts it comes in contact with. It often occurs in 
connection with chlorosis, and not unfrequently complicates 
the later stages of phthisis pulmonalis. It may also result 
from the careless application of strong caustics to the cervix ; 
from exposure to cold and wet ; from the improper use of 
hard pessaries ; and from rough or excessive coition. In 
girls it is sometimes a sequel of one of the eruptive fevers. 

There is occasionally met with, especially in pregnant 
women, a granular form of vaginitis, first described by M. 
Deville, in which the swollen muciparous follicles rise above 
the surface as minute hemispheres. 

Treatment. — The treatment of acute vaginitis in all its 
forms, whether specific or simple, does not materially differ. 
Absolute rest in bed is essential. Warm water injections (see 



44 DISEASES OF WOMEN. 

p. 40} medicated with tincture opii deodorata ( 3 j. to the quart 
of hot water), to which a few drops of fluid extract of bella- 
donna may be added, are of the greatest service. They may 
be repeated every fourth hour till the pain abates, at the same 
time watching the effect of the opiate, and reducing or in- 
creasing the quantity as required. Opium suppositories, per 
rectum, may be used at bed-time to procure rest and sleep. 

After the inflammatory symptoms have somewhat abated, 
much benefit may be derived from inserting a cotton pes- 
sary saturated with glycerine, to which ten grains of plum- 
bum iodidum have been added. This should be changed 
night and morning. It keeps the inflamed surfaces apart, 
unloads the blood-vessels, and tends to heal abrasions. 

Chronic catarrh of the vagina is often benefited by injec- 
tions containing glycerate of iodide of iron freshly prepared. 
Or the protosulphate of iron, recently crystallized (gr. x. to 
the pint) may be used as a wash twice a day. 

PRURITUS VULVAE 

consists in an exalted sensibility of the external genitals, 
attended with intense itching, which prompts the patient to 
scratch the parts, thus aggravating and perpetuating the dis- 
tress. It is generally intermittent. When occurring regu- 
larly at night, accompanied by pains in the tibia, a syphilitic 
origin may be suspected. Pruritus is a symptom more than 
a disease, and we should first try to find out the cause before 
attempting treatment. It is occasionally due to pediculi, 
ascarides in the rectum, acrid discharges from cancer uteri, 
stone in the bladder, diabetes, and the practice of onanism, 
but more frequently is caused by leucorrhoea. The following 
prescription sometimes relieves the intense itchiness : 

Jji> . Goulard's extract | ij. 

Hydrocyanic acid, dilute | j. 

Soft water O j. 

M. 



VULVITIS, VAGINITIS, PRURITUS, LEUCORRHCEA. 45 

Soak a soft cloth with the above lotion, and keep the parts 
constantly wet. If the surface is abraded, the lotion may be 
still more diluted, and the patient warned to watch the ef- 
fect. I have heard of accidents from the too rapid absorp- 
tion of hydrocyanic acid, but never met with one. Dilute 
carbolic acid ( 3 i. of the melted crystals, glycerine ^i., and 
one quart of tepid water) is a good application. One of the 
best, if not otherwise contraindicated, is a strong aqueous 
solution (gr. x. to the ounce) of morphia acetate. Dr. George 
H. Bixby suggests a close-fitting rubber bandage over the 
genitals. 

The affection often persists notwithstanding the most ac- 
tive treatment. If due to disease of the brain or spinal cord, 
local applications will not be of much service. When pruri- 
tus occurs at the climacteric, or later, the prognosis is very 
unfavorable. When caused by diabetes the chances for cure 
would also be small. 

LEUCORRHCEA, 

called dXso Jliior albtcs, and popularly the whites, is the most 
common of all the troubles to which women are liable. It 
has been known from the earliest historic period. Hippo- 
crates describes it, and says it is difficult to cure. Strictly 
speaking, it is not a disease so much as a symptom ; in the 
great majority of cases depending upon some form of uterine 
affection. The color of the discharge varies from white to 
yellowish-green, occasionally streaked with blood. In con- 
sistence it is generally creamy, but may be either viscid or 
watery. It may proceed from the vagina or uterus alone, 
but in most cases is of a mixed character. Occasional secre- 
tions most frequently proceed from the uterus ; when the 
flow is continuous, the vagina is likely to be the principal 
source. Any discharge not sanguineous nor simply aque- 
ous, may be set down asleucorrhoea. 

At one time it was supposed that leucorrhcea was always 
due to inflammation, but this is an error. The secretion 



46 DISEASES OF WOMEN. 

from the vulvo-vaglnal glands may become excessive under 
mental or physical stimuli, without the presence of inflam- 
mation, and the same remark holds true of the rest ; but, if 
the discharge is long continued, it is probably connected with 
an inflammatory state of the membrane, or it may be the re- 
sult of great debility. Leucorrhoea is a frequent sequel to 
congestion ; the glands become hypertrophied, and the extra 
discharge assumes a chronic form. Congestion has a greater 
tendency to occur in mucous membranes than in other tis- 
sues. Leucorrhcea is more apt to affect women who follow 
sedentary occupations, in whom the bowels are habitually 
constipated. 

The '' white-of-egg " secretion, which comes from the cer- 
vix, is originally clear, like raw egg, and alkaline, but on 
coming in contact with the acid mucus in the vagina it coagu- 
lates, like boiled egg. When secreted in excess, the cervical 
discharge may eventually appear transparent, on account of 
the vaginal acid mucus not being present in sufficient quantity 
to neutralize it. When the cervix is abraded, this whitish 
discharge is mixed with a yellow one, varying in proportion 
to the extent of inflammation. The discharge is sometimes 
acrid, and may cause pruritus vulvae. 

Dr. J. Hjaltelin, chief physician of Iceland, says that leu- 
corrhoea is a very frequent affection in that country, "often 
associated with amenorrhoea and painful menstruation or ova- 
ritis. It seems often occasioned by cold feet, and is in most 
cases obstinate and difficult to treat." 

Treatment. — If dependent on uterine disease, as most fre- 
quently it is, the only rational plan would be to remove the 
cause by applying appropriate remedies to the uterus. In 
the comparatively rare cases where leucorrhoea seems to be 
idiopathic, and when the patient Is a virgin, we may begin 
with soothing injections, such as the hot-water douche al- 
ready mentioned, a weak solution of potassium permanganate 
(four grains to the quart of tepid water), an infusion of hops, 
poppy leaves, or chamomile flowers, followed by astringent 



VULVITIS, VAGINITIS, PRURITUS, LEUCORRHGEA. 4/ 

injections after the irritation has subsided. A selection may 
be made from the following formulae : 

1^ . Tannin 1 ss. 

Glycerine 1 ij. 

Rub them together in a mortar, with gentle heat, till dis- 
solved. Add a tablespoonful to a quart of tepid water, and 
inject per vaginam. 

I^ . Plumbi acet 3 i. 

Tepid water cong. j. 

M, 

5. Ferri sulph. exsic gr. xvi. 

Cold water cong. j. 

M. 

^ . Zinci sulph. exsic gr. xij. 

Hot water cong. ij. 

M. 

Alum is a cheap and efficient astringent, much used by 
many practitioners ; but I seldom use it, because it is likely 
to irritate the parts, and even to excite inflammation. If em- 
ployed at all, a weak solution (not more than eight grains to the 
gallon) should be used. Suppositories of cacoa butter, contain- 
ing each four grains of tannin, may be inserted at bedtime. 

Dr. Aveling recommends the employment of arsenious 
acid internally, in the form of granules containing one-twen- 
tieth of a grain after meals, or Fowler's solution, beginning 
with two drops, gradually increased to six, after meals, in 
cases of atonic leucorrhcea. It exercises a decongestlve 
action on all the mucous membranes. 

In most cases it is advantageous to change the astringent 
weekly or oftener. Before using a new solution direct the 
patient to wash out the vagina with a water injection, to 
avoid the inconvenience of chemical precipitates. 

The following unusual (personal) cases are mentioned for 
the purpose of inculcating the necessity of making a vaginal 
examination where there is doubt as to the cause. 



48 DISEASES OF WOMEN. 

Case I. — Dr. Pike, of Peabody, Mass. , sent me a little 
girl, twelve years of age, who had been under the care of 
another practitioner for several months. She was troubled 
with a vaginal discharge, generally thin, but sometimes pu- 
rulent and tinged with blood. Simple and astringent injec- 
tions had been industriously used, without benefit. The 
parents then transferred her to Dr. Pike's care, who ad- 
vised them to consult me. I placed the patient under the 
influence of ether, made a vaginal examination with my little 
finger, and succeeded in extracting a common pin, which lay 
transversely in the Douglas sac. The pin was partially oxi- 
dized and bloody. The vagina was thoroughly cleansed with 
a tepid solution of potassium permanganate. Under Dr. 
Pike's care she entirely recovered within three weeks. 

Case II.— During August, 1871, Dr. Day, of Wakefield, 
Mass., consulted me in the case of an unmarried lady, about 
thirty years of age. Fourteen months previously, in San 
Francisco, she had been violently thrown to the ground while 
riding on horseback. When carried indoors, blood was found 
flowing freely from the vagina, and a tampon of sponge was 
used by the physician in attendance. From that time until 
July, 1871, menstruation had not occurred. It returned in 
July, but a disagreeable odor accompanied the discharge, fol- 
lowed by leucorrhoea. On making a vaginal examination, I 
immediately detected a piece of sponge, as large as a filbert, 
which had probably remained there since the time of the 
accident. Its removal, and vaginal injections, soon effected 
a cure of the leucorrhoea.' 

' The following case was published in the Boston Medical and Surgical Jour- 
nal, April 3, 1844: "I was called to Mrs. F , aged thirty, November 2, 

1836, who was suffering with severe pain in back and lower part of abdomen. 
Since the birth of her only child, three years before, she has had almost constant 
pain in back. On making an examination /^r z/fl-^/waw, I found and extracted a 
steel thimble without a top. It had been left there accidentally by the midwife. 
. . . . She had been attended at different times during the three years by ten 
physicians, none of whom examined her per vaginani, and either one of whom 
might have given her permanent relief had he known the cause of her suffering." — 
E. Bartlett, Jr. , South Berwick, Me. 



CHAPTER IV. 

VAGINISMUS, DYSPAREUNIA, MASTURBATION, 
ATRESIA. 

VAGINISMUS. 

We are indebted to Dr. J. Marion Sims for our knowledge 
of this affection, and the best method of treating it. The 
disease essentially consists in hyperaesthesia of the mucous 
membrane at the vaginal entrance, with spasm of the sphincter 
vaginae. It is a nervous affection, not necessarily associated 
with inflammation. The gentlest touch will excite spasm 
and excruciating pain, so that marital intercourse is next to 
impossible. At one time patients were allowed to remain in 
this state for years, all attempted remedial measures proving 
utter failures ; now the disease is easily recognized, and the 
remedies almost always successful. There are several differ- 
ent degrees of the affection, ranging from mild to severe. All 
depend on the same cause, but the mild cases are more 
likely to be mistaken for hysteria or something else. 

Treatment. — Certain palliative measures may first be tried. 
Chief among these is thorough dilatation of the ostium 
vaginse with the thumbs, while the patient is under the influ- 
ence of ether. Anaesthesia must be carried to the surgical 
degree. This effects temporary paralysis of the sphincter, 
and should be followed by the insertion of a Sims dilator, 
worn two hours daily. Sometimes a permanent cure results. 
This simple method may be supplemented by the use of plum- 
bum iodidum ( 3 ij.) and glycerine ( | ij.), with which the dilator 
is smeared. Or an ointnrent consisting of two grains atropia 
to an ounce of vaseline may be used for the same purpose. 
4 



so 



DISEASES OF WOMEN. 



Dr. Sims' radical treatment consists in removing all ves- 
tiges of the hymen with sharp curved scissors ; this must be 
thoroughly done, and, if practicable, in a continuous piece. 
Even a minute fragment left sometimes prevents success. 
Then, after the bleeding has stopped, make a Y-shaped 
incision through the mucous membrane and part of the mus- 
cular fibres on each side the perpendicular line extending 
into the perineum. A glass vaginal dilator is inserted and 




Vaginal Dilator. 



allowed to remain two hours every morning and evening dur- 
ing one month. An opiate suppository by the rectum should 
be employed for a few nights to allay pain. Dr. Sims' dilator 
is made of several sizes, with a hollow space on the upper 
surface to avoid pressure on the urethra. The outer end is 
open, the inner end closed. 

As far back as the days of Dr. John Burns, author of the 
celebrated book on midwifery, he proposed to divide the 
pubic nerve for this affection. There is not much difference 
between Dr. Sims' operation and the one he proposed. It is 
doubtful, however, if Burns' suggestion was ever carried out 
in his lifetime. Dr. Emmet has modified the above opera- 
tion by putting the sphincter on the stretch, and then succes- 
sively dividing the cord-like muscles with scissors. 



DYSPAREUNIA. 

This trouble is old ; the name only is new. Dr. Barnes, 
■of London, applies it to all cases where sexual intercourse is 
painful or impossible. Dyspareunia may be either congenital 



VAGINISMUS, DYSPAREUNIA, MASTURBATION, ETC. 5 1 

or acquired. When congenital, it depends on some malforma- 
tion of the female genitals, or disproportion between the size 
of the male and female organs. The pubic arch may be un- 
usually deep, thus throwing the vulvar fissure too far back 
for easy intercourse. The difficulty may depend on congen- 
ital atresia, too short a vagina, or too long a cervix. 

In acquired Dyspareunia inflammation is the most frequent 
cause. Any of the pelvic organs — uterus, ovaries, vagina, 
or packing — may become inflamed, and dyspareunia result. 
Chronic pelvic cellulitis, by fixing the womb, is a common 
cause of this afiection. Awkward attempts at intercourse by 
newly married men often give rise to it. Some women, are 
so ignorant about the marital relation that they suppose the 
pain unavoidable, and suffer in this way for years before com- 
plaining to their physician. 

Treatment. — This must be as varied as its causes. If de- 
pending on some malformation, such as a leathery hymen, an 
abnormally small vagina, a caruncle at the meatus urinarius, 
or a fissure at the anus, appropriate surgical measures must 
be had recourse to. The hymen should be excised, the 
small vagina gradually dilated with bougies, the caruncle 
removed, or the anal fissure incised and stretched. 

If acquired, the inflammation must be subdued by perfect 
rest, warm sitz-baths, opiate suppositories, and soothing in- 
jections. All attempts at coitus should be abandoned for 
weeks or months, till inflammation and congestion have sub- 
sided. Newly married couples might in most cases prevent 
irritation by a free use of vaseline. 

MASTURBATION, 

sometimes called Onanism, is more common among children 
and girls, but is occasionally practised even by wives and 
mothers. Masturbation is essentially the same in both sexes, 
for, although seminal emissions follow the act in men, and 
only an increased mucous discharge in women, the cliief 
damage in both sexes consists in nervous prostration. 



52 DISEASES OF WOMEN. 

T\\Q physical c?iUSQS which, in certain cases, result in self- 
abuse are — tumors in the immediate neighborhood of the 
urethra, anal fissure, hemorrhoids, foreign bodies in the blad- 
der (generally introduced by masturbators), caseous matter 
at the base of the nymphae, general uncleanliness of the gen- 
itals, pediculi on the mons veneris, and ascarides in the rec- 
tum, which subsequently enter the vagina. Frequently the 
habit has a mental origin. Lascivious books and pictures, 
impure talk among school-girls, which gives rise to an exag- 
gerated estimate of sexual pleasure, and the force of bad 
example, prematurely stimulate desire and lead to this per- 
nicious habit. Professor Mayer, of Berlin, says: *'The ef- 
fects of masturbation on the mind are the more terrible the 
earlier it is practised. Children lose their vivacity, frankness, 
and docility, become shy, uncommunicative, listless, sad, and 
despondent, and have an aversion to the plays and society of 
their mates." 

There can be no doubt that the tendency to self-abuse may 
be hereditary. Dr. H. R. Storer mentions the case of a 
child, less than six months old, who was observed to be con- 
stantly directing her hands to the pudenda, and the habit 
steadily increased until she was seven years old. 

One of the earliest and most distinctive signs of the prac- 
tice is a frequent call to micturate. The vulva becomes con- 
gested, and the vulvo-vaginal glands secrete much mucus. 
The patient has a downcast, sheepish look, her pupils are 
dilated, her hands impart a cold, clammy sensation, and she 
is subject to fits of vomiting, especially at night. 

Treatment. — When due to physical causes, such as car- 
uncles or ascarides, the source of irritation should, of course, 
be removed. If hereditary influences and libidinous desires 
constitute the motive power, our treatment must be mainly 
moral, for local applications are full as likely to hurt as to 
help the patient. Hygienic measures, sitz-baths, cleanliness, 
plain diet (sedulously avoiding spices and alcohol) and men- 
tal occupation — might be tried. Sometimes sodium bromide. 



VAGINISMUS, DYSPAREUNIA, MASTURBATION, ETC. 53 

in large doses, or other antaphrodislac medicine will prove 
of service. Blisters to the vestibule (to make the parts sore) 
have been recommended. Excision of the clitoris (some in- 
clude excision of the nymphae) has been performed, but, I 
need scarcely add, unwarrantably ; for the seat of sexual 
desire is not located in that region. 



ATRESIA VAGINtE. 

Strictly speaking, the genital canal extends from the vulva 
to the fimbriated extremities of the Fallopian tubes, and 
any part of the canal may be closed, either congenitally or 
as the result of disease. 

In childhood, the labia are sometimes found adherent. 
I have seen two cases during the last twelve years. In one 
girl, six years old, mere pressure by stretching with the 
thumbs sufficed to remedy the defect. In the other, four 
years of age, the little patient was etherized, a probe intro- 
duced, and, by the combined action of pressure from within 
outward, and separation from without inward with the handle 
of a scalpel, I managed to reopen the passage. In both cases 
the labia were kept separate by a pledget of oiled cotton, re- 
newed night and morning for a week. No further trouble 
was experienced. 

We may have closure of the canal from imperforate hymen^ 
in which case the membrane is generally tougher than usual. 
In a new-born child the hymen is rudimentary, and the 
growth from below upward may continue until the opening 
is completely closed. When menstruation sets in, the blood 
is retained in the vagina, and may even dilate the uterus suf- 
ficiently to excite a suspicion of pregnancy. 

Treatment. — The remedy for imperforate hymen is to punc- 
ture the membrane, a simple operation, but not free from 
danger. The admission of air, or the sudden change from 
a state of tension to relaxation, stimulates the womb to con- 
tract, with occasionally the effect of driving a portion of men- 



54 DISEASES OF WOMEN. 

strual fluid through the Fallopian tubes into the peritoneal 
cavity, followed by peritonitis and death. Opinions are di- 
vided as to whether it is better to make a small opening with 
an aspirator needle, followed by slow, gradual drainage, or a 
large opening, and immediately wash out the cavity with a 
warm solution of some disinfectant. The latter method seems 
preferable. After partial evacuation of the retained fluid, the 
hymen should be excised with scissors. Dr. Winsor, of 
Winchester, Mass., reports the following case, an abstract of 
which is here given : ^ • 

Case III. — November 14, 1875, I was summoned to an un- 
married American girl, seventeen years of age, who was suf- 
fering from dysuria. She had never menstruated. The vul- 
var opening was found to be filled by a protruding tumor, 
tense and fluctuating. Palpation showed the abdomen to be 
occupied by a median tumor extending considerably above 
the umbilicus. The catheter passed in the proper direction, 
and drew off plenty of urine without in the least diminishing 
the tumor at the vulva. Dr. C. E. Buckingham was sent for 
in consultation. The largest trocar of an aspirator was thrust 
through the bulging vulvar tumor, Dr, B. making firm pres- 
sure meanwhile on the fundus of the womb above the navel. 
Strong pressure was required to enter the trocar. It was 
several minutes before the fluid began to ooze through the 
canula, thick, dark-brown, and inodorous. Six ounces were 
slowly withdrawn by the aspirator. The abdomen was then 
swathed. The vulvar tumor was decidedly less tense. Pa- 
tient's pulse and respiration were good. Several napkins 
were soaked through by the discharge. Tuesday and Wednes- 
day the abdominal tumor continued to subside. The abdo- 
men was slightly tender; the discharge became -offensive, 
and on Thursday an injection of bromo-chloralum was given 
by the puncture. That evening the temperature was 103° F. 

^ Boston Medical and Surgical Journal, July 12, 1877. 



VAGINISMUS, DYSPAREUNIA, MASTURBATION, ETC. 55 

Next morning she was in good condition, with a pulse and 
temperature neither of which exceeded lOO. But before 
noon she was in great distress, chiefly abdominal. Her 
countenance was sunken and pinched. She was etherized, 
and an incision made at the site of the puncture which would 
admit the finger ; then, with scissors, the hymen was opened 
up to the urethra, down to the fourchette, and laterally to 
each labium minus. Digital examination found the upper 
vagina as large as that of a woman who had borne several 
children. Its lining was coarse and rough. The whole 
amount evacuated since the puncture has probably been six 
quarts. The vagina and womb were washed by a free injec- 
tion of bromo-chloralum, and an oiled plug of oakum was put 
in the vagina. The occluding membrane, where cut by the 
scissors, was one-fourth of an inch thick. [Blood poisoning, 
marked by rigors and a petechial eruption, occurred soon 
after, from which she eventually recovered.] 

The vagina may be congenitally absent, and in such cases, 
the uterus is almost always absent too. It is a strange fact, 
however, which has been noted by Dr. Emmet and other 
careful observers, that the operation for making an artificial 
v^agina, in some cases, develops a rudimentary uterus and 
improves the general health. 

Accidents in early life, such as falls from a height on 
sharp pieces of wood which impale the vagina, may result 
in contraction or closure of the tube,^ and atresia is fre- 
quently caused by sloughing and adhesions after a severe 
labor. 

Rarely we find a transverse septum mJdway, with an open- 
ing only large enough to allow egress to the menstrual fluid. 
Or the septum may be longitudinal, constituting a double 
vagina. I operated in 1867, on a married v/oman, in whom 
the septum was half an inch wide, attached by one end to the 

' See Boston Medical and Surgical Journal, March 24, 1881, for a case in 
point. 



56 DISEASES OF WOMEN. 

anterior vaginal wall, near the cervix uteri, and by the other 
to the posterior vaginal wall near the ostium vaginae. Both 
attachments were successively divided by means of a wire 
ecraseur, and no bad result followed. 

Case IV. — Mrs. F., twenty-eight years of age, married 
fourteen months, was first seen by me in February, 1875, at 
Dr. William F. Stevens' office,' Stoneham, Mass. On at- 
tempting to make a vaginal examination, the finger was ar- 
rested by a sort of diaphragm about one inch from the vulva. 
The uterine sound could be passed with difficulty through a 
small opening in the centre of this membrane, and here the 
menstrual fluid had found a vent. An examination per rec- 
tum revealed the uterus in its normal place. The obstruction 
was not a thickened hymen, for the latter had been freely in- 
cised fourteen years previously, and ocular inspection proved 
that there was a narrowing of the canal at the place of attach- 
ment. 

The following day, with the asisstance of Dr. Winthrop F. 
Stevens, I proceeded to operate. The patient was fully ether- 
ized, a small bivalve speculum introduced, an Atlee's guarded 
knife passed through the small aperture, and three slight inci- 
sibns made, two lateral and one inferior. The speculum was 
then withdrawn, a metallic dilator passed through the open- 
ing, and the membrane torn by slowly expanding the instru- 
ment, whilst a finger was kept in the rectum. Then, removing 
the dilator, the operation was completed by introducing one 
finger and afterward two fingers up to the posterior cul-de- 
sac. A large cotton plug, saturated with glycerine and a lit- 
tle laudanum, was left in the vagina. Next day one of Dr. 
Sims' glass dilators was introduced, and worn, at intervals, 
for three weeks without discomfort. 

Mrs. F. was examined by me two years after the opera- 
tion. No narrowing had taken place, and both husband and 
wife were well satisfied with the result. Her sister informs 
me that she has since borne a living child. 



VAGINISMUS, DYSPAREUNIA, MASTURBATION, ETC. 5/ 

Dr. Emmet gives the details of an interesting case of atre- 
sia vaginae, in which the knife was used five times unsuccess- 
fully during a period of eighteen months, and finally cured 
by tearing the parts instead of cutting them. After an inter- 
val of nineteen months there was no subsequent contraction 
of the vagina/ He strenuously objects to the use of porous 
plugs (as sponge, cotton, lint, or oakum), as favorable to 
blood-poisoning, insists on the importance of completing the 
operation at one sitting, advises the daily insertion of a glass 
dilator for a long time, and, till the parts heal, the frequent 
employment of antiseptic injections. 

1 Emmet on Vesico- Vaginal Fistula, p. 136, 



CHAPTER V. 

AMENORRHCEA, DYSMENORRHCEA, MENORRHAGIA, 
METRORRHAGIA. 

AMENORRHCEA 

consists in the absence of the menstrual flow, between pu- 
berty and the menopause, in a woman. who is not pregnant 
or suckHng a child. Strictly speaking, it is not a disease it- 
self so much as a prominent symptom of uterine or ovarian 
disease. It may result from the rudimentary state or entire 
absence of the uterus and ovaries. In some cases, amenor- 
rhoea depends on superinvolution of the womb following 
labor, complicated with atrophy of the ovaries. The pro- 
cesses of degeneration and absorption are carried beyond the 
normal limit, the uterus becomes smaller and thinner than 
natural, and the monthly secretion is arrested. As already 
pointed out, it may be due to imperforate hymen, in which 
case the fluid accumulates in the vagina and womb, failing to 
make its appearance only for want of an opening. These 
are really cases of hcematometra. 

Patients affected with amenorrhoea may be divided into 
two classes, namely, first, those in whom the discharge has 
never appeared ; and, second, those in whom, from some 
cause, it has become abnormally suppressed. 

To understand the reason of its absence one must have 
some idea of the cause of its presence. Four things are more 
or less concerned in its production : 1st, An extra flow of 
blood to the uterus and ovaries takes place — hyperaemia ; 2d, 
Ovulation is more active ; 3d, Degeneration of the outer layer 
of the uterine lining membrane occurs ; 4th, Blood is shed 



59 

from the same surface and makes Its appearance externally. 
When the ovaries are congenitally absent, menstruation never 
sets in; and, in most cases, when both ovaries are removed, 
the process is soon arrested. The first step is called nidatioHy 
from the idea that a '* nest" is thus prepared for the ovum, 
where it will grow, if previously impregnated by contact with 
a healthy spermatozoon. The third process is called denida- 
tio7i, or a throwing off of the ' ' nest," because it is not needed. 

In temperate climates, the majority of girls commence to 
menstruate about fourteen, fifteen, or sixteen years of age. 
When menstruation is delayed beyond sixteen we have 
ground to suspect constitutional disease or sexual malforma- 
tion. In scrofulous subjects the menses are frequently late 
in making their appearance. In young girls with a tendency 
to phthisis the flow is often arrested entirely, or makes its 
app^earance irregularly; and in chlorotic or ansemic women 
amenorrhoea is a common symptom. On the other hand, this 
affection occurs as a sequence of high living, and we are sur- 
prised to find robust, plethoric- looking women complain of 
arrested menstruation, without being able to assign any rea- 
sonable cause for the stoppage. 

When not dependent on constitutional disease or sexual 
malformation, amenorrhoea most frequently results from ex- 
posure to cold, wet feet, bathing near the menstrual period, 
or mental emotion. 

Treatment. — If the menses have never appeared, and the 
patient has been subject to occasional paroxysms of pain in 
the pelvic region, lassitude, and dysuria, similar to those often 
experienced at the commencement of menstruation, a vaginal 
examination should be made to ascertain w^iether there is any 
mechanical obstruction present. If the vagina is patent, re- 
course should be had to constitutional remedies adapted to 
the particular case. In anaemic subjects some preparation 
of iron will be advisable. The freshly prepared saccharine 
carbonate of iron, in two-grain doses after meals ; or tincture 
of the muriate, five drops In a wineglassful of lemonade twice 



6o DISEASES OF WOMEN. 

a day ; or dialyzed iron in eight-drop doses twice a day ; or 
phosphate of iron in powder may be used with advantage. 
Sometimes an acid solution of cinchonidia or quinine is pre- 
ferable. 

If the womb is infantile, the primary current of electricity 
applied daily, one electrode inside the os uteri and the other 
on the lumbar region, for several weeks, sometimes succeeds 
in starting development, followed by menstruation. The 
flow may at first be irregular, but, as the general health im- 
proves, it finally becomes regular. A feeble secondary cur- 
rent, in certain cases, is preferable to the primary one. In 
some cases a galvanic stem pessary helps to start the men- 
strual flow. 

The treatment for amenorrhoea of the second class is neces- 
sarily more varied. Arrested menstruation may possibly 
depend on pregnancy, and before taking any steps to bring 
on the flow we must try to find out that conception is not the 
cause of its arrest. This can only be ascertained satisfac- 
torily by a bi-manual examination. If the patient is not anae- 
mic, chlorotic, or phthisical, and especially if she is married, 
the presumption is that conception has occurred. In making 
a vaginal examination, the uterine sound must not be used. 
After waiting a reasonable length of time (four or five months), 
and being satisfied that the stoppage is not due to pregnancy, 
we should make inquiries as to the habits and mode of life. 
Amenorrhoea may be owing to disorders of digestion, over- 
eating, over-heated rooms, constipation, indolence, mental 
excitement or depression. It is scarcely necessary to say 
that the first step should be to alter the mode of life. Simple 
purgation by means of magnesium sulphate or elixir proprie- 
tatis in small doses, warm sitz-baths at bedtime, restricted 
diet, and total abstinence from fermented liquors, may prove 
sufficient. If not, abstraction of blood from the cervix uteri 
may be tried. Moderate out-door exercise, sleeping on a 
hard mattress, and daily sponging with cold water, are good 
adjuvants. 



AMENORRHCEA, DYSMENORRHCEA, ETC.. 6l 

But if the patient is pale and sickly-looking, and more es- 
pecially if the arrest of menstruation has come on gradually, 
the treatment must be mainly directed to a restoration of the 
general health. It 'not unfrequently happens that gradual 
arrest of the flow is supplemented by a leucorrhoeal discharge, 
which, to some extent, takes the place of the natural secre- 
tion. In such cases iron is the best emmenagogue. 

Where the flow is suddenly arrested, followed by a chill 
and feverishness, the best remedies are rest in bed, hot fo- 
mentations to the lower part of the abdomen, warm drinks ; 
and an enema of aloes and soda in hot water after the fever- 
ishness has subsided. 

Case V. — October, 1870. Mrs. C, twenty-nine years 
of age, the wife of a farmer, married ten years, no children 
nor miscarriage. Has not menstruated during the last four 
years. Has had monthly exacerbations resembling the on- 
set of her turns with leucorrhoeal discharge for several days. 
No leucorrhcea to speak of at other times. Patient robust, 
weighs one hundred and sixty pounds. Appetite good, 
bowels regular, no dysuria, sleeps well at night. Occasion- 
ally troubled with severe headache ; at times dull backache. 

Made a bi-manual examination ; found the uterus small, 
sharply anteflexed, so that an ordinary sound did not enter 
more than three-fourths of an inch. A speculum examina- 
tion revealed slight abrasion of the os, and redness of the 
cervix, which was smaller than natural. After many trials a 
Simpson intra-uterine pessary (copper and zinc) was in- 
serted and worn for a week without discomfort. It was then 
removed, and after the lapse of three days again inserted. 
The best way to introduce a stem pessary is first to pass a 
silver probe, which can then be used as a guide. 

In Mrs. C.'s case menstruation never returned (1880) ; 
but the headache and backache were much relieved. Inter- 
nal remedies were tried from time to time without any salu- 
tary effect. 



62 DISEASES OF WOMEN. 

DYSMENORRHCEA 
may be defined as diflicult and painful menstruation. The 
flow may be profuse or scanty, but more frequently the lat- 
ter. Four distinct varieties are mentioned by authors. These 
are: ist, Neuralgic; 2d, Inflammatory; 3d, Obstructive; 
4th, Membranous. Dr. Thomas gives a fifth variety — the 
Congestive — but as partial congestion is the normal state of 
the uterus and ovaries during menstruation, it seems super- 
fluous. As the treatment of each variety requires to be 
adapted to the special cause, I will discuss them separately. 

I. Neuralgic. — The occurrence of this variety has been 
called in question by Dr. Barnes and others. The late Dr. 
Gooch describes a disease under the name of '' Irritable 
Uterus " which is near akin to the variety in question, and is, 
in fact, often associated with it. There can be no doubt that 
cases occur neither dependent on inflammation nor obstruc- 
tion, attended with severe pain at the menstrual periods, in 
which the nerves distributed throughout the pelvis play the 
principal part. Delicate, nervous women are more subject 
to this form of the affection ; but I have seen several cases 
in strong, robust women. 

Treatment. — The best treatment is rest in the horizontal 
posture for two days before, during, and after the flow, with 
teaspoonful doses of viburnum compound in hot, sweetened 
water every two hours until relieved. A hot salt-bag (con- 
taining not less than four pounds of salt), applied to the 
lower lumbar region, sometimes gives relief. The late Sir 
James Simpson advises the introduction of a stream of car- 
bonic acid gas into the vagina as a sedative, but this remedy 
is not always a safe one. A piece of absorbent cotton soaked 
with twelve drops of chloroform may be laid over the groin 
and covered with a watch-glass. As a palliative : 

^. Hoffman's anodyne Ij- 

McMunn's elix. opii 3 ij. 

Liq. ammoniae acet 1 ivss. 

M. Dose : A teaspoonful every hour if needed. 



AMENORRHCEA, DYSMENORRHCEA, ETC. 6^ 

Quinine should be administered in tonic doses during the 
intervals. Neuralgic dysmenorrhoea is apt to be associated 
with hysteria, and in our treatment this circumstance re- 
quires to be recollected. Tinct. Gelseminum (gtt. viii. every 
four hours) may be tried. 

2. Inflammatory. — This is a common form of the affec- 
tion, and most frequently follows inflammation of some one 
of the pelvic organs. The pain does not wholly subside in 
the intervals between the catamenial flow. There is always 
a sense of fulness or weight in the pelvis ; and as the period 
approaches the pain increases in severity, with feverish symp- 
toms superadded, such as heat, thirst, dry skin, headache. 




Fig. i6. — Pinkham's Scarificator. 

and nausea. If a vaginal examination is made, the womb 
feels heavy, somewhat prolapsed, and very sensitive, the 
vagina is hot and swollen, and sometimes there is dysuria. 

Treatment. — Remedial measures should be mainly directed 
to curing the disease which lies at the root of the trouble. 
If dependent on a previous attack of pelvic peritonitis, or one 
of endometritis, the appropriate remedies for these affections 
must be employed. In most cases the patient should be re- 
stricted to a simple farinaceous and milk diet, such as well- 
boiled flour porridge, barley and milk, or sugar gingerbread 
and milk. If at all constipated, saline laxatives combined with 
belladonna, or a solution of aloes and sqda (aloes 3ij.; so- 
dium bicarbonate 3 iv. ; boiling water O j.; dose, a wineglass- 
ful) will prove serviceable. If the liver is at fault, hepatic 
pills (pil. hydrarg. gr. iij.; ext. colocynth, comp., ext. hyoscya- 



64 DISEASES OF WOMEN. 

mus, aa, gr, j.) may be given at bedtime, onje every other day 
for a week. 

In this, as in all other forms of dysmenorrhoea, rest is a 
remedy of the highest importance. The narcotic palliative 
already mentioned may be given in soda-water hourly until 
four doses have been taken. Free scarification with Dr. 
Pinkham's intra-uterine scarificator, a day or two before the 
flow is expected, followed by the hot vaginal douche, are 
often beneficial. 

3. Obstructive dysmenorrhoea may be caused by a con- 
genitally narrow canal, by stricture at the external or internal 
OS uteri, or by sharp flexions of the uterus. It may also 
arise from the presence of a polypus or a fibroid tumor in 
the cervix. The pain is often so severe as to compel the pa- 
tient to go to bed. Violent headache, nausea, and vomiting 
prostrate her for a time, and are apt to recur at each men- 
strual epoch. 

Treatvieiit.' — The best way is to dilate the canal gradually 
wath metallic bougies. Sometimes the mere passage of a large 
sound the day before menstruation sets in will result in a pain- 
less flow. If due to an elongated cervix with a contracted os 
externum, it can be relieved by partial incision with scissors, 
keeping the cut surface patent till it heals. The slit should 
never be carried up as high as the os internum. She should 
remain in bed at least four days, and not go out of doors for 
two weeks. If due to flexion, insert a suitable pessary. 

If the menstrual fluid is retained for several days, it may 
partially coagulate and clots form a portion of the discharge; 
or It may decompose and smell badly, in which case there is 
risk of septicaemia. On this account the greatest attention 
should be paid to cleanliness, using warm vaginal injections 
with a minute quantity of iodine dissolved in the water. 

To relieve pain^ use opium suppositories per rectum, or 
hypodermic injections of morphia (with a little atropia) twice 
a day. Hot salt-bags may also be applied to the lower lum- 



AMENORRHCEA, DYSMENORRHCEA, ETC. 65 

4. Membranous. — This is a rare form of dysmenorrhoea, 
and seems to depend on exfoliation of the uterine mucous 
membrane. It is more common among married than single 
women, and by some authors is looked upon as a species of 
early abortion. Where an entire cast of the body is thrown 
ofif with two small openings corresponding to the Fallopian 
tubes, and one larger opening opposite the os internum, 
studded all over its smooth internal surface with puncta of 
the utricular glands, there can be no doubt that it is a layer 
of the normal mucous membrane, similar to the membrana 
decidua, but the question whether such a cast is necessarily 
associated with conception still remains sub jiidlce. There 
are also certain cases in which the cast consists oi fibrin and 
mucus, like that formed in diphtheria. Severe pains like those 
of labor, set in a day or two before the flow, and relief fol- 
lows the expulsion of the membrane. 

This form of dysmenorrhoea sometimes depends upon a 
syphilitic taint. In any case it is very difficult to cure. The 
superficial layers of mucous membrane undergo fatty degen- 
eration, and are thrown off" in coherent patches. Female 
workers in match factories are particularly liable to the dis- 
ease. The phosphorus used acts as a poison. 

Treatment. — The interior of the uterus should be carefully 
dried with bibulous paper (such as that employed by den- 
tists), and a few drops iodide of phenol or acid nitrate of 
mercury applied to the body of the womb. As a general 
rule, it is unsafe to inject fluid of any kind into the non-preg- 
nant womb with a common syringe. Even when the process 
is preceded by dilatation of the cervix, and a double catheter 
is used, it is not free from danger. But the following ar- 
rangement, devised by Dr. Emmet, is quite safe. Tie a very 
small piece of sponge over the bulbous nozzle of a uterine 
syringe charged with a few drops of the fluid to be used ; 
pass the nozzle so covered to the fundus ; press out the fluid, 
which will be entirely absorbed by the sponge, and as it is 
withdrawn the fluid will be squeezed out on the mucous 
5 



66 



DISEASES OF WOMEN. 



membrane. A camel's-hair pencil or a sponge-probang has 
its contents used up as it enters the cervix, and little or none 
of the fluid reaches the upper part of the womb. Carbolic 

acid, tincture of iodine, iodide of 
phenol, or chromic acid, may be ap- 
plied in this way. Buttles' intra- 
uterine syringe, covered at the uter- 
ine end with cotton, answers the 
same purpose. 

Pain is best relieved by dilatation 
with laminaria or slippery-elm tents 
before the flow sets in, followed by 
free scarification beyond the inter- 
nal OS. Narcotics are sometimes 
necessary, of which the best are 
opium suppositories or laudanum in- 
jections by the rectum. 

Dr. Priestley, of London, describes 
a peculiar form of dysmenorrhoea 
which occurs about the middle of the 
inter-menstrual period, generally ac- 
companied by a more copious secre- 
tion of mucus in the vagina. 



MENORRHAGIA 




IS excessive 

periodically. It is an exceedingly 
difficult matter to accurately ascer- 
tain the normal amount of the men- 
strual flow, partly because of the 
natural variation within the bounds 
of health in different persons, and 
partly on account of the method usually employed by wo- 
men in collecting it. As nearly as can be estimated, the 
amount each month varies from two to six fluid ounces. In 



Figs. 17 and 
uterine Syringe. 



8.— Buttles' Intra- 
(After Munde.) 



MENORRHAGIA. 6/ 

making Inquiries it is usual to ask how many napkins have 
been soiled. Eight each month would be a liberal allow- 
ance. Before resorting to treatment the following points 
should be carefully ascertained : the age of the patient, the 
probability of pregnancy, the state of the general health, and 
the presence or absence of a uterine tumor. If the general 
health remains unaffected for a considerable length of time, 
we could scarcely call even a very copious flow menorrhagia. 

Much will depend on the age at which the attack occurs. 
It is not uncommon in robust girls to have menstruation com- 
mence with an excessive flow ; neither is it unusual to have 
the menopause preceded by menorrhagia. Some women 
flow copiously during the early months of pregnancy. A 
still larger number of cases depend on a vitiated state of the 
general health, poor, watery blood, a relaxed system, obsti- 
nate constipation, or a sluggish liver. And in not a few, the 
excessive flow can be traced to the presence of a polypus, a 
fibroid tumor, or a warty state of the lining membrane, or to 
cancerous degeneration. In all these cases congestion plays 
a prominent part. 

Treatment. — Rest in bed on a firm mattress, light cover- 
ing, cool acidulated drinks (aromatic sulphuric acid in ice- 
water), two-grain pill of Squibb's aqueous extract ergot 
every two hours ; or fluid extract cannabis indica, in doses of 
sixteen minims four times a day ; or powdered opium in 
grain doses, repeated hourly till four doses have been taken. 

After the flow.has stopped, find out the cause, if possible, 
and treat accordingly. If a polypus is present, remove it. 
If the patient is plethoric, give saline laxatives and reduce 
her diet. If she is anaemic, give some form of iron. If de- 
pendent on ''change of Hfe," constitutional treatment, with 
mental and moral management, will prove most serviceable. 
In cases of warty excrescence, scraping the internal uterine 
surface with a curette,^or the insertion of a carbolized sponge- 
tent (the patient remaining in bed for several days), give the 
best results. The mucous surface should be painted several 



62. 



DISEASES OF WOMEN. 



times, at intervals of a week, with strong tincture of iodine. 
Dilatation of the cervix with Ellinger's dilator, or a sponge- 
tent, in some cases, has proved successful. 

When the hemorrhage results from in- 
cipient cancer, scrape the parts affected 
with Sims' sharp curette, and apply an al- 
coholic solution of bromine (ten to twenty 
per cent.), taking the usual precautions 
to avoid injuring sound tissue. The ac- 
tual cautery is our last resort. 

METRORRHAGIA 

might be defined as excessive flow with- 
out regularity, not occurring immediately 
after labor at term. When due to preg- 
nancy it is usually called uterine hemor- 
rhage or flooding, and the quantity may 
be small in amount and intermittent- 
The absence of periodicity is the princi- 
pal difference between menorrhagia and 
metrorrhagia. 

The common causes are, inflammatory 
engorgement, granular degeneration of 
the mucous membrane, uterine fibroid 
tumors, polypi, retained products of con- 
ception, cancer, and depraved blood from 
any cause which lowers the general health. 
Long-continued absorption of poison — 
as in those who habitually employ hair- 
FiG. 19.— sJms' Sharp Curette, dycs contaiulug Icad, workers in match 

[In Sims'" Uterine Surgery." - ^ . , .,, ,-1,1 11 

p. 61; or Munde's "Minor factoncs aud ill-ventilatcd workshops, ar- 

Gynecolog>-," p. 287.] • 1 • • r 11 • u j 

senical poisonmg from wall-papers m bed- 
rooms — tends to deprave the blood and results in metrorrhagia. 
Treatment. — This is substantially the same as that already 
detailed for menorrhagia. Absolute rest is essential. On ac- 




METRORRHAGIA. 69 

count of the greater suddenness of the onset, we sometimes 
require to plug- the vagina or uterus. Absorbent wool, 
dusted with powdered alum and sugar. In small rolls, each 
tied with a string, may be used to fill the vagina. But the 
most efficient and rational tampon Is a carbolized sponge- 
tent passed into the cervical canal. A piece of smooth gen- 
tian root, or several pieces of slippery-elm bark, make a ser- 
viceable plug. They should be dipped in a weak solution of 
iodine, or Monsel's styptic, immediately before use. 

Ergot can be given internally, of which the best form is 
Squibb's aqueous extract. Infusion of digitalis is also a 
good remedy. 

Dr. G. H. Lyman, of Boston, recommends dilatation of the 
cervix beyond the inner os, and cites several successful cases 
treated by this method. He uses tents, but the same re- 




FiG. 20.— Ellmger's Dilator. 

suit may be attained with a good dilator, such as Ellinger's. 
The following case is abridged from his report : 

Case VI. — Miss D., aged twenty-eight, applied in Sep- 
tember, 1876, for relief from exhausting metrorrhagia. For 
four years she had never been so free from hemorrhage as to 
permit her to dispense with a guard. A small laminaria tent 
was inserted, with marked benefit. Five months later, along 
journey brought on profuse menstruation for a week, but since 
then the periods have been regular, with a normal flow only. 
These (and similar) facts seem to indicate that the hemorrhage 
was in some manner influenced by constriction of the inner os, 
causing congestion and strangulation of the mucous membrane. 



CHAPTER VI. 

INFLAMMATION AND LACERATION OF CERVIX 

UTERI. 

The external surface of the cervix is often inflamed. This 
inflammation may at first be slight, without abrasion or solu- 
tion of continuity ; but after a time there is always more or 
less loss of substance, the epithelium disappears, and a raw 
surface results. After the muco-pus, in which the surface is 
bathed, has been wiped ofl", the villi present a granular ap- 
pearance. In health, mucous membranes do not secrete an 
appreciable quantity of mucus ; absorption is as rapid as se- - 
cretlon ; but when blood stagnates in the capillaries, the 
membrane becomes congested, inflamed, and finally abraded. 
The broken-down tissue irritates the neighboring parts, and 
leucorrhcea follows. 

Much discussion has occurred in reference to the true na- 
ture of this affection, and especially in regard to its correct 
nomenclature. What some call inflammation, others call 
congestion. The late Dr. Tyler Smith, of London, looked 
upon destruction of the epithelial covering as simply abra- 
sion, while Dr. J. Henry Bennet occupies a large part of his 
masterly work on ''Inflammation of the Uterus" with argu- 
ments that this state of things Is true ulceration. In this 
work, a long-continued increase of mucous secretion, accom- 
panied by redness of the cervical surface, is always spoken of 
as inflammation, and a rough granular surface, deprived of 
its epithelium and readily made to bleed, is set down as abra- 
sion. Prof. Simon defines ulceration as " the process by 
which holes are made through the surface textures of the 



I 



INFLAMMATION OF CERVIX UTERI. 7 1 

body, a process which differs from gangrene mainly in the 
fact that it proceeds more gradually and molecularly." Dr. 
Macleod, of Glasgow, says: **The terms desquamation, or 
excoriation, or abrasion, are applied to the removal of epi- 
thelium alone, while ulceration implies a deeper penetration 
of the destructive action." 

One fact goes far to corroborate the assumption that true 
inflammation exists in the cervical mucous membrane ; it is 
the accumulation of chlorides in that tissue. This can be 
easily demonstrated by lightly touching the surface with lu- 
nar caustic — a dense white precipitate is formed immediately. 
We know that in pneumonia the chlorides accumulate in the 
lung-tissue, and are almost entirely absent from the urine, a 
diagnostic sign we take advantage of in that disease. 

Many causes tend to produce inflammation of the cervix 
and to prevent healing after granulation has once occurred. 
One of the most frequent is endometritis. The cervical dis- 
charge, like that from nasal catarrh, irritates and inflames the 
OS uteri and neighboring parts ; and the friction attendant 
upon walking and working finally rubs off the congested 
epithelium. Too frequent sexual intercourse, especially when 
indulged in near the menstrual period, when the uterus is 
physiologically congested, is a frequent cause of cervical in- 
flammation. Dr. Emmet first pointed out that eversion of 
the cervix, following laceration during labor, is often mis- 
taken for ulceration of the external surface. The internal 
mucous membrane is turned inside out by the split cervix 
rolling up anteriorly and posteriorly. 

Inflammation of the cervix is occasionally attended with 
numbness of one side, generally the left. The lower extrem- 
ity is more frequently affected than the upper. ^ The cervix 
is often hypertrophied and indurated as a result of inflamma- 
tory infiltration. 

Treatment. — When the inflammation depends upon uterine 

' See Dr. Haltoii's article in Dublin Journal of Medical Science for June, 1876. 



']2 DISEASES OF WOMEN. 

catarrh, we must first direct our attention to the cure of that 
disease. ■ In granular abrasion, the rough surface may be 
scraped with a curette, and strong carboHc acid carefully ap- 
plied after it has stopped bleeding. Scarification is often 
necessary when the cervix is much congested. A small te- 
notomy knife answers very well for this purpose. Some pre- 
fer the application of leeches. 

In severe cases it may prove necessary to apply iodide of 
phenol to a small surface, not larger than a dime. Acid ni- 
trate of mercury, or an alcoholic solution of bromine, may be 
similarly applied. Care must be taken, in using strong acids 
or alkalies, to thoroughly protect the vagina (see p. 39). 
These remedies are not intended to " melt down " the cervix 
directly, but only to stimulate the absorbents, as was long 
ago demonstrated by Dr. Bennet. For this purpose he was 
in the habit of employing occasionally a stick of potassa cum 
calce. I have used caustic soda in certain obstinate cases, 
and have even applied the actual cautery at a white heat with 
positive benefit. But it is seldom necessary to employ such 
heroic remedies. 

Absorption of plastic tissue is promoted by the use of the 
hot douche twice a day (see p. 40). The patient may also 
be taught how to insert a cotton pessary, saturated with gly- 
cerine, and medicated according to the nature of the particu- 
lar case. If she is anaemic, and the vagina relaxed, " iron- 
cotton " ^ might be advantageously substituted for the plain 
article. It should be changed once or tv/ice every day. In- 
stead of iron the cotton tampon may be steeped in James' 
styptic (a saturated solution of resin in alcohol). The vaginal 
moisture precipitates the resin, which acts as an astringent 

^ *' Take the finest purified cotton-wool, wet it thoroughly with water, squeeze 
all the water out, and then saturate it with a mixture of liq. ferri subsulphatis and 
water (one part to two), press it out into layers an eighth of an inch thick, about 
the size of the hand ; these layers are to be pressed between the hands, or on the 
side of the bowl containing the mixture, till they are nearly but not quite dry, 
and then they are to be stuffed into a large wide-mouthed bottle, securely corked, 
and kept ready for use." — Dr. Sims in N. Y. Med. Journal, April, 1874. 



IxNFLAMMATION OF CERVIX UTERI. 73 

and styptic. Particular attention must be paid at the men- 
strual periods to the observance of rest in the horizontal pos- 
ture, and the avoidance of work calculated to increase con- 
gestion, such as driving a sewing machine, sweeping, ironing, 
and lifting heavy weights. 

If It is a case of eversion, the rugous Inner lining being ex- 
posed to view, the only rational remedy Is to freshen the 
callous surfaces, bring them into apposition with tenacula, 
and put In wire stitches. This would necessitate rest In bed 
for at least a week after the operation. In freshening the 
flaps a trumpet-shaped strip in the centre is left undenuded 
to avoid atresia. Dr. Emmet, to whom we are indebted for 
directing attention to this lesion, strongly urges the necessity 
of Instituting suitable preparatory treatment before operating. 
All traces of cellulitis should first be removed, and the con- 
tiguous parts restored to a healthy state. 

Case VII. — The following (unpublished) case occurred In 
the practice of Dr. F. W. Graves, Woburn, Mass.: ''During 
the spring of 1878, I was requested to see Mrs. H., a 
young married lady, residing in Bayonne City, N. J. She 
was thirty-two years of age, and the mother of two children. 
She enjoyed uninterrupted health until the birth of her last 
child, four years previous. Her labor at that time was very 
severe, and there was considerable /6'^/-/«^r^?^;;2 hemorrhage, 
which probably came from the cervical rent. From then up 
till the time she consulted me she suffered greatly from neu- 
ralgia, bearing down, pain in the back, inability to walk, and 
hysteria ; the catamenia were painful and protracted. On 
making an examination with the speculum, a left lateral lacer- 
ation, extending from the os to the vaginal junction, was dis- 
covered. The edges were everted, the surfaces congested, and 
quite freely studded with degenerated mucous cysts. I made 
no application at first, but ordered frequent injections of hot 
water. Afterward the cysts were punctured, and the entire 
surface painted with iodine. 



74 DISEASES OF WOMEN. 

'' On October 7th, the patient being etherized, I trimmed 
out a mass of cicatricial tissue from the bottom of the rent, 
vivified the edges, brought them together with silver-wire 
sutures, and placed the patient in bed. She remained there 
two weeks, and then returned to her home. After the 
lapse of four months her husband wrote me a letter, in which 
he said, ' Mrs. H. continues to improve ; no more ner- 
vousness, no more hysteria, no more fainting — in fact, none 
of the old troubles.' I saw her again in July, 1879, when she 
reported herself perfectly well." 



CHAPTER VII. 
METRITIS— ENDOMETRITIS. 

METRITIS. 

Acute metritis, or inflammation of the substance of the 
womb, is a rare affection. When it does occur, in the non- 
pregnant state, it is most frequently caused by surgical op- 
erations, or follows rude attempts at procuring abortion. It 
may result from a fall, from wearing an intra-uterine pessary, 
or even from a sudden arrest of the menstrual flow. Fibroid 
or cancerous growths may possibly end in acute metritis. 

The disease is characterized by sudden severe pain in the 
body of the womb, with paroxysmal exacerbations, rigors, 
'nausea, distressing emesis, and fever. Defecation and mic- 
turition are both painful. A vaginal examination, or pres- 
sure above the pubis, always aggravates the pain. The va- 
gina feels shorter than natural, hot, and tumefied, and the 
womb itself is swoHen. Acute metritis is liable to be con- 
founded with cystitis, although a digital examination after 
passing water should enable us to avoid this error. 

Acute metritis generally ends in resolution within two 
weeks. I have only seen one fatal case, which occurred in a 
young unmarried woman, and was probably caused by the 
rough treatment of a female abortionist. Dr. Ashford, of 
Washinp;ton, crives the details of a similar case, which ended 
in suppuration. This result is rare.^ I have met with two 
other cases : one was correctly diagnosticated, pus formed, 
was evacuated, and the patient recovered ; the other I 

^ Report of Columbia Hospital, 1873, p. 253. 



76 DISEASES OF WOMEN. 

only saw after death, and the true nature of the disease was 
not discovered during life. The disease is more common 
after parturition. It may assume a chronic form, and it is 
likely to be complicated with endometritis. 

T7'eatment. — Absolute rest in bed is essential, the patient 
lying on her back. Apply leeches to the pubis and peri- 
neum. Administer opium freely in the form of suppositories 
and hypodermic injections. If the bowels are loaded, give a 
warm enema ; but it is not good practice to give cathartics. 
Much benefit may be derived from the hot vaginal douche. 
At least two gallons should be used each time, and the pro- 
cess repeated several times a day. Flannel cloths wrung out 
of hot water, and covered with oiled silk, may be substituted 
for poultices. A paste of soft extract belladonna ( 3 j.), mixed 
with iodide of lead (3j.). ^^^d glycerine ( Jj.), on cotton bat- 
ting, maybe placed over the pubis. When the discharge has 




Fig. 21. — Double Current Catheter. 



an offensive odor, intra-uterine injections, through a double - 
current catheter, of some disinfectant (potassium permanga- 
nate, or an aqueous solution of iodine) are serviceable, pro- 
vided the canal is sufficiently open. 

After the inflammation has somewhat subsided, a series of 
small blisters may be raised over the pubis. The following 
is a rapid, cleanly, and efficient way to raise blisters : Take 
an iron rod, with a flat knob eight lines in diameter, and a 
wooden handle ; heat the knob in boiling water and apply 
for a few seconds to the surface indicated. Two or more of 
these small blisters may be produced at one sitting, taking 
care to leave an interval of one inch or more between each 



METRITIS — ENDOMETRITIS. ^J-J 

blister. The same end may be attained with the cantharidal 
vesicant. Sometimes it is advisable to apply blisters at an 
earlier period, especially when there are signs of inflamma- 
tion spreading to the neighboring tissues. 

Chronic metritis may be confined to the body of the 
womb — called corporeal metritis, or to the cervix — cervical 
metritis, of which the former is much more intractable. In 
corporeal metritis the lower part of the posterior wall is most 
frequently affected. 

The symptoms are backache ; dull, dragging pains behind 
the pubis, increased by attempts to walk ; pain during defe- 
cation and micturition ; all these pains increase at the men- 
strual period. Pressure of the uterine body between a finger 
in the vagina and the other hand externally, demonstrates 
the existence of inflammation. The bladder should be 
emptied before trying this test. When the disease is confined 
to the cervix, that part is enlarged, sodden, and painful, 
and the os is patulous. The lining membrane is always af- 
fected. Nausea is a common symptom. Sterility is apt to 
follow chronic metritis. 

Treatment. — Similar to that already described for the acute 
disease, modified by the comparative mildness of the symp- 
toms, and their longer duration. Short rests in the recum- 
bent posture during the day, occasional scarifications, hot- 
water douches, small blisters on the cervix, and opiate sup- 
positories, constitute the main features of the treatment. 

In corporeal metritis, a plasma of iodide of lead in glyce- 
rine carried up to the fundus on a pledget of cotton, or the 
same material applied by means of Dr. Taliaferro's cloth- 
tents, may prove useful. These tents are made by rolling a 
narrow strip of linen in the form of a cone, to the broad end 
of which a strong double thread is attached to assist in re- 
moval. They may be employed to wipe out the uterine cav- 
ity, after being soaked in hot water. A clean one is then 
saturated with the medicine indicated, and allowed to remain 
in the cavity for twelve hours. The pledget of cotton-wool, 



78 DISEASES OF WOMEN. 

wrapped round the bulb of a probe, is only used to carry- 
up the medicine, and is not itself left in the womb. Dr. 
Gerould strongly recommends the bromide of iodine to the 
fundus as a stimulating solvent. It may be dissolved in 
glycerine (ten per cent.), but must be cautiously used, as it is 
apt to irritate and inflame the adjacent parts, even when di- 
luted to this extent. Much benefit results from the long- 
continued use of cotton pessaries, saturated with glycerine. 
They serve to deplete the gorged cervix, and at the same 
time support the heavy womb, enabling the patient to take 
gentle out-door exercise without being annoyed by the usual 
disagreeable dragging sensation. 

In some cases the cure is facilitated by the application of a 

Hodge's lever pessary. Hard-rubber pessaries, in great va- 

^gg^ riety, may be had at the surgical-instru- 

^^^^^ ment stores, but in general I prefer a 

w^ ^L^ simple ring of block-tin, which can be 

^^ ^^^^ readily bent into the required shape with 

^^^ ^^^ ^^ fingers, and at the same time is firm 

^'^k ^k enough to maintain its shape when 

^^ ^H placed in the vagina. The only objec- 

^^^M^^ tion to block-tin is the facility with 

^^ which it conducts heat if left iii situ 

Fig. 22. — Hodge's Lever Pes- ^ -^ ^ 

sary. while the patient takes her hot douche. 

She might be instructed how to remove it before taking the 
douche, and how to replace it afterv/ard. A series of ten or 
twelve sizes plain rings should be kept on hand by the sur- 
geon. The greatest pains must be taken in fitting a pessary, 
so as to avoid pressure on the urethra, or jamming of any 
part. It should be mobile, and distend the vagina as little as 
possible. To insure a fit, repeated trials must be made. If 
its presence causes pain or the slightest discomfort, something 
is wrong. Flexible pessaries, which can be moulded with the 
fingers, are now made of celluloid, and seem to work well. 
A properly fitted pessary gives support to the heavy uterus, 
prevents irritating friction of the inflamed cervix on the va- 



METRITIS— ENDOMETRITIS. 79 

ginal wall, and allows the relaxed ligaments to regain their 
tone. The surgeon should ascertain, from time to time, that 
it is not pressing unduly on the womb or any part of the va- 
gina. I have seen several cases where serious injury resulted 
from carelessness in fitting pessaries, and sometimes from 
wearing them too long without examination. Until the pa- 
tient herself becomes sufficiently familiar with the proper way 
to insert and withdraw it, the surgeon should examine at 




Fig. 23.— Block-tin Pessary. 

least once a week. Where a pessary requires to be worn for 
a long time, it would pay to get one made of gilt-silver tubing, 
the block-tin one serving as a pattern. 

Women recover from metritis, and subsequently bear chil- 
dren. This, as Dr. Barnes points out, is good evidence of 
a cure. But in the chronic form, after the lapse of years, it 
is doubtful if complete recovery often takes place. It is, in- 
deed, a most intractable disease. 

ENDOMETRITIS, 

or inflammation of the lining membrane, sometimes called 
uterine catarrh, is a very common affection. Inflammation 
may be confined to the neck, or it may attack the whole in- 



8o DISEASES OF WOMEN. 

ternal surface — the former most frequently. Scrofulous and 
phthisical women are more liable than others to this disease. 
It is divisible into acute and chronic. 

Acute endometritis may arise from a sudden chill caused 
by exposure to cold, especially during menstruation, or it 
may follow a severe labor or a miscarriage. It may consti- 
tute the sequel of an attack of gonorrhoea, and occasionally it 
comes on after scarlet fever or small-pox. 

The symptoms are dull pain in the pelvis, a sense of weight, 
backache, headache, dysuria, and, after a time, a muco-puru- 
lent discharge. Examination with the Cusco speculum at an 
early period reveals a reddened, highly congested cervix, a 
gaping OS, from which issues a transparent, jelly-like mucus. 

Treatment. — Rest in bed, as far as practicable ; free scari- 
fication with Pinkham's intra-uterine scarificator, repeated 
after a few days ; the hot-water douche at least twice a day, 
and opium rectal suppositories at night, constitute the best 
remedies, under the use of which the patient may reasonably 
be expected to recover within a month or six weeks. 

Chronic endometritis is a very common disease, often 
continuing for months or years before the patient applies for 
assistance, or is aware of the nature of her trouble. In most 
cases it is not attended with severe pain, and the attendant 
disagreeable sensations are chiefly reflex in their character. 
Nearly every case is complicated with leucorrhoea more or 
less profuse. Occasionally the discharge is so abundant that 
she requires to wear a napkin, and sometimes it is so acrid 
as to excoriate the labia. The patient complains of head- 
ache at the vertex (which is often bald for the space of an 
inch or more), backache in the dorso-lumbar region, loss of 
appetite, occasional nausea, pain in the ovaries (most fre- 
quently the left), and a peculiar disagreeable sensation linder 
the left breast. There is also a tendency to hysteria. 

The cervix is found somewhat enlarged. On making a 
speculum examination, glairy, tenacious mucus may be seen 
issuing from the os ; and the external surface of the cervix is 



METRITIS — ENDOMETRITIS. 8 I 

inflamed, sometimes abraded and everted. The entire vagi- 
nal mucous membrane may be affected, especially when pre- 
ceded by gonorrhoea ; but generally the inflammation is con- 
fined to the cervix. In virgins, sterile wives, and aged 
women the disease is most frequently limited to the cervical 
canal, and there may be little or no inflammation of the ex- 
ternal surface of the neck. When confined to the cervix, the 
natural contraction at the internal os remains ; but if the 
membrane lining the body is also inflamed, the uterine sound 
readily passes to the fundus, and its withdrawal is followed 
by blood. 

I have met with one well-marked case of corporeal endo- 
metritis, dependent on stenosis of the internal os, and charac- 
terized by a collection of about two drachms of muco-puru- 
lent matter, w^hich I evacuated by dilatation with a laminaria 
tent. Within a year the os contracted again, and matter 
collected a second time. After its evacuation the cavity was 
washed out with a warm solution of Condy's fluid, and 
painted with a plasma of iodide of lead. 

Treatment. — It is of very great importance to pay atten- 
tion to the general health. If the bowels are habitually con- 
stipated, appropriate steps should be taken to remedy this 
defect. Among these diet holds the first place. Oatmeal 
porridge, cracked wheat, fruit as a part of every meal, and a 
glassful of cold water on rising in the morning, will help to 
regulate the bowels. Friction over the abdomen, beginning 
at the lower part of the right side and rubbing ?//>, kneading 
the transverse colon across, and rubbing dozvn the left side, 
helps to stimulate the natural peristaltic motion. I have 
found the " Relaxation " pill a useful adjuvant. 

5. Aloes socotrine 3j- 

Scammony gr. xx. 

Alcoholic ext. belladonna gr. xv. 

Pulv. glycyrrhizae q. s. 

M. Divide into sixty pills. One at bedtime. 
6 



82 DISEASES OF WOMEN. 

If the liver is torpid, a " hepatic " pill (Pil. hydrarg. gr. iij.; 
ext. colocynth comp.,ext. hyoscyami, aa. gr. j.)may be given 
every alternate day for a week. Indigestible food, pastry, 
and confectionery, should be avoided, and particular atten- 
tion paid to the state of the skin. Passive exercise in most 
cases will promote the cure ; and pure air, both night and 
day, must be provided. In chronic cases there is a tendency 
to despond, which can best be combated by general hygienic 
measures. We should bear in mind that in confirmed cases 
of uterine disease, which it maybe have existed for years, 
the blood itself has become depraved, and the whole nervous 
system organically affected as a consequence of imperfect 
nutrition and constant pain. Dr. Henry M. Field recom- 
mends the oxalate of iron in such cases ; and, when constipa- 
tion complicates the blood-depravation, prescribes arseniate 
of iron with good effect. 

The local treatment consists, first, of remedies which re- 
lieve congestion, such as free scarification, the hot douche, 
and pledgets of wool or cotton saturated with glycerine, 
changed every twelve hours ; second, puncture of the Nabo- 
thian cysts, which frequently stud the outer surface of the 
cervix like duck-shot ; third, application of sedatives and re- 
solvents, such as tannin, carbolic acid, iodine, or zinc sul- 
phate, as already described (p. 39); fourth, frequent spells of 
rest on a lounge through the day, and sleeping at night on 
a mattress so raised at the bottom that the patient's legs and 
pelvis shall be higher than her shoulders. The following 
(personal) cases will further serve as illustrations of treatment : 

Case VIII. — Mrs. T., thirty-seven years of age, called at 
my office February 11, 1873. Has been married ten years, 
and is the mother of two children, one five years, the other 
fourteen months old. So far as she knows, nothing unusual 
occurred at either birth. From girlhood menstruation has 
always been painful. She has not been well since the birth 
of her last child. Menstruation returned five months ago. 



METRITIS— ENDOMETRITIS. 83 

She complains of dull, heavy, almost continuous pain in oc- 
ciput, severe backache, and leucorrhoea ; the discharge is 
sometimes streaked with blood. Appetite poor and irregu- 
lar, bowels constipated, smarting sensation after passing 
water. Sleeps well at night. Does not keep house. 

On examination found the ostium vaginse inflamed ; also 
the meatus urinarius. Inserted small size Cusco speculum. 
The cervix was inflamed and abraded, and a copious flow of 
glairy mucus issued from the os. Washed out the vagina, 
wiped the cervical canal with cotton swabs, and applied equal 
parts of strong carbolic acid and glycerine. Before with- 
drawing the speculum a pledget of cotton saturated with 
tannate of glycerine was placed close to the cervix, with di- 
rections to remove it at bedtime. 

This treatment was continued weekly during three months, 
leaving an interval of ten days at the menstrual periods. 




■J. pif: VNOizt^ s — c o 

Fig. 24. — Cupping Cylinder, 



During that time the cervix was freely scarified twice, fol- 
lowed by cupping with Thomas* hard rubber cylinder, here 
delineated. LugoFs solution of iodine was occasionally ap- 
plied ; and the patient was instructed to wash out the vagina 
daily with a tepid solution of potassium permanganate. Dis- 
charged nearly well. 

Case IX. — Mrs. M., Winchester, Mass., aged thirty- 
eight years. Has had eight children, of whom six are still 
living ; youngest two years old. Has been complaining for 
ten months. Appetite poor ; food distresses her ; bowels 
moderately regular. Three months ago her menses lasted 
for nine days ; did notreturn for six Aveeks, and only a slight 
show then. Complains of headache, heartburn, and a burn- 
ing pain in lower part of abdomen. 



84 DISEASES OE WOMEN. 

Made an examination August 5, 1872. Found an offen- 
sive discharge ; the cervix enlarged, Indurated, and Inflamed. 
The vaginal mucous membrane near the cervix was soft and 
spongy, so that the insertion of the speculum, even with the 
greatest care, caused bleeding. The parts were syringed out 
with a w^eak solution of carbolic acid, freely scarified, and a 
cotton-pledget saturated with glycerine inserted. The hot 
douche was used twice a day. A solution of iron (tincture 
of the muriate) was applied during part of the time. In 
about six weeks she was so much improved that attendance 
was discontinued. She became pregnant in the following Oc- 
tober, and was safely delivered in due season. 



CHAPTER VIIL 

PELVIC PERITONITIS, PELVIC CELLULITIS, 

fELVIC PERITONITIS 

is a circumscribed inflammation of the peritoneum covering 
tlie organs lying in the pelvis. It may become general, and 
spread to the entire peritoneal membrane ; but more fre- 
quently it is confined to that portion covering the pelvic 
organs. In its mild form it is a very common affection. 

Pelvic peritonitis may occur after delivery, and it is not 
uncommon in nullipara. In a great majority of cases it is a 
sequel to disease of the womb, Fallopian tubes, or ovaries. 
When it occurs prim.arily it is usually sudden in its onset, 
attended by alarming symptoms of severe pain, chills, and 
nervous shock. The disease is comparatively rare after the 
menopause. It may follow an attack of gonorrhoea, the in- 
flammation spreading from the vagina to the uterine lining 
membrane, and thence along the Fallopian tubes to the peri- 
toneum and ovaries. It may be caused by sudden suppres- 
sion of the menses. 

The principal sequel is plastic effusion, binding down the 
uterus, and even encroaching on the rectum. This state of 
things may be followed by suppuration, more especially if the 
patient has been reduced by previous disease, or is of a stru- 
mous constitution. Dysmenorrhoea is also apt to follow where 
the womb is fastened by-perimetric deposits. 

Treatment. — In the acute form, absolute rest should be en- 
forced. Leeches, followed by poultices, and the free admin- 
istration of opium both by the mouth and rectum, are the 



86 DISEASES OF WOMEN. 

best remedies. Cathartics should be sedulously avoided ; 
and, if necessary, the bladder may be emptied by the cathe- 
ter to insure local rest. Spongio-piline, or tow, soaked in 
hot water, are good substitutes for poultices. After the first 
stage has passed, small blisters (size of a cent), frequently 
repeated, constitute the best agency to relieve pain and pro- 
mote absorption. The hot douche, continued for half an 
hour or longer every night and morning, should be employed. 
The diet ought to be very plain — milk, eggs, beef-tea, and 
stale bread. 

In the chronic form, which is often a tedious complaint, 
gentle carriage exercise, and even a moderate amount of 
walking may be allowed. Bleeding is not needed ; but nu- 
merous small blisters kept up for weeks will often work won- 
ders in the way of cure. Potassium iodide, combined with a 
vegetable tonic — as gentian — and administered in a large 
quantity of watei*, often proves serviceable. The disease is 
apt to be aggravated at the monthly periods. 



PELVIC CELLULITIS 

is inflammation of the connective tissue which binds the pel- 
vic organs together, and, although not rare, is less common 
than pelvic peritonitis. It is possible that either the perito- 
neal covering, or the cellular tissue may be inflamed without 
the other being afl°ected ; but both are involved after a time, 
with suppuration as a result in many cases. This is the 
** pelvic abscess" of the older writers. Prof. Virchow pro- 
poses the term perimetritis as a substitute for pelvic perito- 
nitis, and parametritis for pelvic cellulitis ; but these terms 
are not as expressive, and should be discarded. 

Pelvic cellulitis is most likely to occur after labor, or after 
surgical operations on the pelvic organs. On account of its 
situation, being generally located in one of the broad liga- 
ments, the swelling is easily reached. For the sam.e reason 
the uterus is not as much bound down as in pelvic peritonitis, 



PELVIC CELLULITIS. 87 

but usually may be moved in some directions. Suppuration 
is a common sequel. The thigh is sometimes retracted in 
consequence of painful irritation communicated to the psoas 
magnus muscle, and the inguinal glands are frequently swol- 
len and tender. The attack is ushered in with chills and 
fever, followed by severe pain in one of the iliac regions. 
The swelling at first consists of serum, so that if opened at an 
early period serum only will be discharged. Pus may form 
later and be liberated. Suppuration is sometimes attended 
with hectic fever. Occasionally <^oagulable lymph is depos- 
ited, and such cases are always tedious. 

Treatment. — This is substantially the same as that already 
detailed for pelvic peritonitis, and may be summed up under 
the heads of absolute rest, leeches, hot douches, and opium 
to the verge of narcotism. In pelvic cellulitis there is not the 
same objection to laxatives. Hepatic pills (one night and 
morning), followed by small doses of sodium phosphate, may 
generally be given with advantage. After the more urgent 
symptoms have been subdued, small blisters should be applied 
over the hypogastrium or in the groin. Greater care than 
usual is necessary at the subsequent menstrual periods for a 
long time. 



CHAPTER IX. 

PELVIC ABSCESS, HEMATOCELE, SEPTICEMIA, 

PYEMIA. 

PELVIC ABSCESS 

may result from cellulitis^ peritonitis, or hematocele, either 
in the puerperal or non-puerperal state, but most frequently 
the former. It includes a collection of pus between the 
layers of the broad ligament on either side, in the Doug- 
las fossa, in the inguinal canal, between the uterus and blad- 
der, in the labia, or in fact in any place about the pelvis 
where cellular tissue abounds. The ancients supposed that 
all purulent discharges proceeded from the womb ; but this is 
a rare occurrence. 

The symptoms consist of throbbing pain in the pelvis, 
increased when walking or standing, and also during defeca- 
tion and micturition, chills and fever alternating, thirst, and 
profuse clam.my perspiration. On making a bimanual ex- 
amination, a tumor more or less tense may generally be 
detected. When the abscess is located laterally, the thigh 
on that side is drawn up, and cannot be straightened with- 
out severe pain. 

Treatment, — If discovered early, an attempt may be made 
to promote resolution by enjoining absolute rest in bed and 
applying leeches, followed by hot fomentations. Generally 
that stage has passed before we see the patient, and our only 
resource is a free opening to let out the pus, prevent bur- 
rowing, and relieve distress. But as in most cases we require 
to work almost in the dark and be guided by the sense of 



PELVIC ABSCESS. 89 

touch, there is some risk of dangerous hemorrhage. To 
obviate this as much as possible it is advisable to wait until 
the abscess begins to point, and even then it is better to 
make a small incision only, into which a pair of uterine 
forceps can be inserted and the opening enlarged by tearing. 
The sac should be washed out twice a day with some warm 
disinfectant solution. If the abscess bursts spontaneously 
and a fistulous tract results, the fistula must be slit up or 
otherwise got rid of on general surgical principles. 

Good nourishing diet, fresh air, change of air, and thorough 
cleanliness, form essential items in the treatment. 

C^SE X. — Mrs. G., a lady living apart from her husband, 
sent for me in great haste November 4, 1872. I found her 
suffering severe pain. The physician in attendance told me 
that there was something seriously wrong in the pelvic 
cavity. On making a vaginal examination with two fingers 
of the left hand while pressure was made above the pubis 
with the right hand, I found a fluctuating tumor in Doug-, 
las' cul-de-sac, which extended more firmly to the anterior 
pouch, and prevented access to the cervix uteri. I told him 
that it was an abscess, and received permission to open it. 
While making pressure preparatory to using the lancet, the 
abscess burst, my fingers passing into the sac, a large quan- 
tity of fetid pus was evacuated, after which the cervix could 
easily be reached. The vagina was thoroughly washed out 
with a tepid solution of potassium permanganate four times a 
day ; the patient put on four-grain doses of quinia sulphate 
night and morning for two weeks, along with generous diet, 
and she made a rapid recovery. 

The following' case illustrates the fact first pointed out by 
Dr. J. Matthews Duncan, that collections of pus may remain 
encysted for years in a fluid state without bursting or be- 
coming decomposed. 

Case XI. — Mrs. S., a young married woman of Irish 



90 DISEASES OF WOMEN. 

extraction, first noticed a swelling as large as a hazel-nut in 
the right labium soon after the birth of her first child in 187 1. 
She has since given birth to other two children, and at pre- 
sent (January, 1878) is seven months pregnant with a 
fourth child. 

After the birth of her last child the tumor rapidly enlarged 
and is now of an oval shape, about four by five inches. She 
applied to Dr. William F. Stevens for advice, who sent her 
to me. The tumor was moderately tense, distinctly fluc- 
tuating, and was not connected in any way with the bladder. 
A fine aspirator needle was inserted, and half a teaspoonful 
of purulent fluid withdrawn. On Sunday, January 20, with 
the assistance of Drs. Stevens and Abbott (the patient Being 
etherized), a short incision was made at the lowest part of 
the tumor, and a pint of grumous, coffee-colored fluid, as 
thick as cream and quite inodorous, was drawn off by means 
of a trocar and canula. The opening was then enlarged 
sufhciently to admit the forefinger, the sac washed out with a 
strong solution of carbolic acid, and a carbolized tent left 
in the opening. It ceased to discharge at the end of three 
weeks. Th^ patient did well. She carried her child to the 
full term and was safely delivered. 



PELVIC H.^MATOCELE, 

also called hematoma, peri-uterine haematocele, and retro- 
uterine hsematocele, consists essentially of a collection of 
blood forming a tumor in the pelvis. There are two distinct 
varieties, one being situated outside, the other inside the 
peritoneum, called respectively extra- and intra-peritoneal 
blood tumors. We are indebted to Bernutz, Nelaton, and 
other French surgeons for our first knowledge of the affec- 
tion. Drs. Tilt, McClintock, and Simpson first drew atten- 
tion to it in Great Britain. 

In most cases the attack occurs suddenly. The woman 
becomes faint and deadly pale, followed, on regaining con- 



PELVIC HEMATOCELE. 9I 

sciousness, by severe pain in the pelvic region. The accident 
is most hkely to occur at or about a menstrual period. At 
first the blood is fluid, communicating to the finger a sense 
of obscure fluctuation. After a few days the blood coagulates, 
and the clots may finally soften and break down. When 
blood collects inside the peritoneal cavity it almost neces- 
sarily occupies Douglas' cul-de-sac. This is the most fre- 
quent seat of the collection. The blood generally comes 
from ovarian vessels which ramify between the layers of the 
broad ligament. More rarely it proceeds from the ruptured 
sac of an extra-uterine gestation. When extra-peritoneal, 
burrowing in the areolar tissue in front of the uterus, the 
tumor is often small and elongated.' 

This disease may possibly be confounded with pelvic peri- 
tonitis or pelvic cellulitis ; but the suddenness of the attack, 
followed by shock, and the absence of inflammation, should 
serve to clear up the diagnosis. Hgematocele is an accident 
more likely to occur in the non-pregnant woman, and cellu- 
litis generally follows a severe labor. In hsematocele the 
tumor at first is fluid, becoming firm afterward ; in cellulitis the 
tumor is hard at first, and softens after a time. We should 
try to ascertain whether the tumor is inside or outside the 
peritoneum. The former occurs more frequently and is also 
more dangerous. Intra-peritoneal hsematocele is marked by 
greater constitutional disturbance, and is more apt to be fol- 
lowed by peritonitis. The tumor is higher situated, and the 
vagina not so much occluded as in the extra-peritoneal vari- 
ety. It is possible also to mistake the blood tumor for a 
retroverted uterus, an error which may be avoided by using 
the uterine sound. If the instrument passes forward, and the 



' Blood may be poured out into the vulva as the result of a blow, or from the 
rupture of varicose veins. Such a heematocele is more likely to occur during or 
soon after labor ; although it-may take place at other times. The celebrated 
John Hunter, in his " Treatise on the Blood," p. 170, gives the details of such a 
case. 



92 DISEASES OF WOMEN. 

womb can be felt at the pubis, the tumor in Douglas' sac 
must be something else, and probably haematocele. 

Treatment. — Shock, which is the most alarming symptom 
in the early stage, is best combated by the free administration 
of iced champagne, or very small doses of brandy in iced 
soda-water. To relieve the pain, powdered opium is the 
surest agent (gr. j. every hour till the pain abates). To pre- 
vent a repetition of the hemorrhage, absolute rest should be 
enforced ; the bed-pan and catheter used when the bowels 
and bladder need to be emptied ; a hard mattress or sofa to 
lie on ; the simplest and least stimulating food administered ; 
the room kept cool and well aired ; visitors excluded, and all 
sources of excitement interdicted. Small doses of infusion 
digitalis (fl. 3 ij.), repeated every hour till an ounce has been 
given, act as a heart tonic and help to stay further bleeding. 

As a general rule, it is better not to open the sac. But 
if inflammation supervenes, attended by chills, fever, night- 
sweats, high temperature, and loss of appetite — septicaemia 
or pyaemia — we must make a free opening in the most de- 
pendent portion, which is generally to be found behind the 
cervix. During the continuance of the discharge wash out 
the cavity at least twice a day with some disinfectant solu- 
tion. At this stage the patient should have a liberal diet, 
with cinchonidia or other tonics. ^ 



SEPTIC.^.MIA. 

Piorry gave this name to the disease produced by the 
absorption of putrefying matter through a fresh wound. 
Septicaemia may follow any simple surgical operation near 
the pelvis, insertion of sponge-tents, and so forth, but more 
commonly occurs after severe labors and ovariotomy. . The 
poison is carried into the circulation principally by the lym- 
phatics. Its distinguishing feature is insensibility to pain 
combined with a high fever; the temperature is high, some- 
times rising to 107° F. ; there is loss of appetite ; rapid, weak 



SEPTIC/EMIA, PY.^MIA. 93 

pulse ; dry, coated tongue, and a tendency to stupor ; the 
breath has a sweetish odor, like new hay. Diarrhoea occa- 
sionally supervenes, and is a grave symptom. The post- 
mortem appearances are a dark, fluid state of the blood, the 
viscera being softened and congested. Abscesses and throm- 
bi, so common in pyaemia, are seldom present. 

Treatuieiit. — This is principally prophylactic. Most surgi- 
cal operations should be performed under a cloud of carbolic 
acid spray ; the instruments should be scrupulously clean, 
and the operator, with his assistants, not less so. In making 
vaginal examinations, the surgeon's finger-nails may be filled 
with softened soap, a simple but effective plan to prevent the 
lodgment of septic matter. 

When septicaemia follow^s severe labors, it generally makes 
its appearance a few days after delivery, and runs a rapid 
course. If the source of infection (a piece of retained pla- 
centa, torn membrane, or decomposing blood-clot) can be 
discovered, remove it, and wash out the parts with a warm 
disinfectant fluid. It is astonishing how soon a patient will 
rally when the ** stock" from which the poisonous fluid is 
being evolved has been removed. If septicaemia occurs after 
ovariotomy (generally w^ithin two weeks) intra-peritoneal in- 
jections, as practised by the late Dr. Peaslee, give the best 
chance for recovery. The administration of quinine, in re- 
peated small doses, is worth trying. 

PYEMIA. 

This disease is another form of blood-poisoning, in which 
the mischief is mainly due to absorption of pus by the veins. 
It is similar to the surgical fever of the older authors, and al- 
most invariably follows a wound or a suppurative inflamma- 
tion of low type, such as. occurs in uterine phlebitis or car- 
buncle. Pyaemia is characterized by great constitutional 
depression, and the deposit of thrombi and metastatic ab- 
scesses. 



94 DISEASES OF WOMEN. 

The attack generally commences with a shivering fit, fol- 
lowed by fever, hot pungent skin, mawkish breath, quick and 
feeble pulse, brown tongue (clean on the edges), and high 
temperature (103° to 107° F.), succeeded in a few hours by an 
equally rapid fall. Recovery or death generally takes place 
within eight days. The purulent matter may be absorbed 
from inflamed lymphatics or veins. Lymphatics abound in 
the cellular tissue which surrounds the uterus, and they are 
especially plentiful near the junction of the cervix and corpus 
uteri. 

Treatment. — If the disease occurs after labor, or after a 
severe surgical operation in the pelvic or abdominal cavities, 
the first thing to be done is to wash out the parts (uterus, 
vagina, or abdomen) with a weak, warm solution of iodine. 
If fetid diarrhoea supervenes, give copious warm water ene- 
mata, in which a little sulphite of soda has been dissolved. 
The patient's strength should be sustained by milk, eggs, 
broths, and wine. Quinine, in small doses frequently re- 
peated, serves to modify and control the pyrexia. 



CHAPTER X. 

RETROVERSION, RETROFLEXION, ANTEVERSION, 
ANTEFLEXION. 

RETROVERSION. 

In a healthy woman the fundus uteri points toward the 
abdominal wall near the median line. When retroverted, it 
points to the sacrum, and may even lie below the promontory. 
This is an accident which is more likely to occur to women 
who are, or have been recently, pregnant. Retroversion may 
occur suddenly as the result of a fall, a misstep, or a blow ; 
from straining at stool or lifting a heavy weight ; and, 
under such circumstances, is almost invariably attended with 
severe pain, inability to pass water, painful defecation, nausea, 
and shock. 

When retroversion occurs gradually, that is, in chronic 
cases, the result is generally dependent upon one of two 
causes, i. The uterus becomes congested and enlarged from 
the presence of a fibroid tumor in the ^posterior wall of the 
body, or from subinvolution after delivery, and a certain 
degree of prolapsus occurs. Under these circumstances, a 
distended bladder, straining at stool, or even much stooping 
at work, may gradually retrovert the uterus. 2. In aged 
women the uterus becomes atrophied, the padding of fat 
is absorbed, the round ligaments become weak, prolapsus 
occurs, and the fundus, gradually falls back into the hollow 
of the sacrum. 

Tilting of the pelvis into line with the spinal column, which 
occurs to some extent in stooping and kneehng, also tends to 



96 



DISEASES OF WOMEN. 



produce retroversion. The pressure of the abdominal viscera 
forces the womb downward and backward. In rare cases, 
adhesions following retro-uteri tie haematocele may gradually 
drag the fundus backward as absorption of the serum takes 
place. Gangrene of the bladder, in which the entire mucous 
lining exfoliates, is one of the sad results of neglected retro- 
version. 

Treatment. — In an acute case, the patient generally sends 
for help because she cannot urinate, and the first step is to 




Fig. 25. — Cutter's Retroversion Pessary. 



empty the bladder with a soft catheter. It may also be neces- 
sary to clear out the bowel by an enema. She should then 
be placed in the knee-elbow position, and pressure upward 
made on the fundus with tw^o fingers in the vagina, while the 
other hand depresses the uterine neck behind the pubis exter- 
nally. Sometimes it is necessary to pass two fingers into tho 



RETROVERSION. 97 

rectum, pressing the fundus upward and sideways (to avoid 
the promontory of tlie sacrum) and at the same time with a 
finger in the vagina hook down the cervix. Many women 
dishke the knee-elbow position ; it is not essentiaL She 
may He on her left side, with knees drawn up, and hips ele- 
vated by a hard cushion, the other steps taken being similar. 
Where pregnancy is suspected, the uterine sound should not 
be used. In some cases, as in virgins, the sound assists 
us as a repositor ; but great care must be taken to avoid 
entering a Fallopian tube or pushing it through the uterine 
wall. 

In a chronic case, attention should first be directed to 
relieve the congestion by scarifications or leeches, the hot 
douche twice a, day, and the insertion of cotton pessaries satu- 
rated with glycerine. The uterine neck may also be painted 
with a solution of iodine. A fortnight after menstruation 
has ended, an attempt may be made to replace the womb. 
Afterward it is kept in place by a block-tin pessary fashioned 
after the Albert-Smith pattern. Should this fail, recourse 
may be had to Cutter's pessary, which is fitted with an exter- 
nal support. The inventor says : 

** This includes a belt of inelastic webbing three feet long, 
one and one-fourth inch wide, to go square around the waist, 
and a suspensory cord of rubber tubing, ten inches long and 
one-fourth inch in diameter, attached to the middle of the belt 
by a loop and cord. This tubing is to run through the natal 
furrow (between the buttocks), and is also attached to the 
perineal extremity of the pessary. It insures an elastic 
support, and the furrow prevents lateral motion. The pes- 
sary is a cylinder of hard rubber, curved into a hook. In the 
middle of the hook there is a joint, so that it may be turned 
out of the way during defecation. 

•* The patient should be placed on the left side, lying upon 
a table. The uterus isTeinstated by the uterine sound, and 
held there. Having determined the length of the post vagi- 
nal wall, and ascertained the size of the womb, we select a 
7 



98 DISEASES OF WOMEN. 

pessary one-half inch longer than the measurement, and with 
a loop large enough to admit the uterine neck. The loop 
pessary is then introduced behind the uterine sound, and 
pushed over the sacrum up into place. The sound is with- 
drawn from the womb. A hold being kept on the suspensory 
cord, it is passed up between the buttocks, and not relaxed 
until the belt is fastened square round the waist." 

Case XII. — Mrs. D., a French Canadian, about thirty 
years of age, had been delivered of her fourth child six weeks 
before I was called to see her. She complained much of 
dysuria, and inability to walk without suffering. On making 
a vaginal examination, I found the womb entirely retro- 
verted. It was with some difficulty that a Simpson's sound 
was inserted, first pushing up the fundus from the rectum ; 
but as soon as that was done the womb was readily replaced 
by making a half turn and depressing the handle, thus lifting 
it past the side of the sacral promontory. A cotton plug 
saturated with glycerine was then inserted, and the patient 
instructed to remain in bed for a week. The bladder was 
previously emptied by a flexible catheter. No further trouble 
was experienced. 

RETROFLEXION 

occurs more frequently than any other displacement, espe- 
cially in women who have previously borne children. It 
consists in a bend at the junction of the uterine neck and 
body, the fundus being tilted backward. In some cases the 
cervix retains its normal direction, whilst in others the entire 
organ is retroverted as well as retroflexed, and the os lies 
close to the pubis. In some the flexion is congenital ; but 
metritis following childbirth or abortion is the common 
cause. 

The usual symptoms are pain in the lower part of the 
spine, dragging sensations, pain over the pubis, shooting 
pains in the groin, dysuria, and dyschezia. Sometimes she 



RETROFLEXION, ANTEVERSION. 99 

is troubled with persistent nausea and vomiting. The men- 
strual flow Is generally lessened In quantity ; but when retro- 
flexion Is accompanied or caused by subinvolution, menor- 
rhagla commonly occurs. 

To distinguish this aflection from a fibroid tumor in the 
posterior wall, or from Impaction of f^ces, the uterine sound 
is needed. If it passes to the fundus anteriorly, and can be 
felt through the abdominal wall above the pubis, of course 
there can be no retroflexion. If the sound requires to be much 
bent, passes posteriorly, and on making a half turn carries 
the mass felt through the rectum out of reach of the finger, 
no doubt need be felt as to the nature of the trouble. It 
should be borne in mind, however, that, in old cases, the 
fundus uteri may be fastened firmly by adhesions. The 
uterine wall, sooner or later, becomes abnormally thinned at 
the point of flexion. 

T^'eatment. — This is similar to that already given for 
retroversion. Congestion should be relieved by free scarifi- 
cations, the fundus replaced, and kept in place with a block- 
tin pessary. It not unfrequently happens that a cotton plug 
saturated with glycerine, and renewed twice a day, proves 
the most satisfactory method of treating this troublesome 
displacement. The bladder should be emptied often enough 
to prevent undue distention. When metritis Is absent, and 
all other remedies fail, a stem pessary may be cautiously tried 
and the result closely watched. The stem must be short, to 
avoid impinging on the fundus. 

ANTEVERSION 

consists in the uterine body leaning unduly forward on the 
jladder, with the cervix tilted upward nearly out of reach, 
before puberty anteversion may almost be reckoned normal ; 

. nd in some women ^his infantile condition remains during 
ife. It is more common in the unmarried and sterile than in 

ihose who have borne children. 



ICO 



DISEASES OF WOMEN. 



Anteversion may be caused by chronic endometritis, 
tumors in the corpus uteri, subinvolution after delivery, 
excessive indulgence in coitus, relaxation of the utero-sacral 
ligaments, shortening of the round ligaments, or by sudden 
pressure from above. 

The symptoms, when any are present, are frequent mic- 
turition, painful locomotion, shooting pains in the- thighs, 
nausea, and leucorrhoea. The patient's sufferings are usually 
aggravated at the menstrual period. More than ordinary 
care must be taken not to mistake the symptoms of early 
pregnancy for those of unnatural displacement, and where 
there is any ground for doubt, the sound should not be used. 
It is better to trust to bimanual palpation, by means of which 
we can often recognize the displacement. 

Treatment. — The first thing is to relieve congestion by 
scarification or leeches. If the external os is too small, make 




Fig. 26.— Cutter's Anteversion Pessary. 



shallow bilateral incisions, and keep the surfaces apart with a 
short laminaria or slippery-elm tent. This simple operation 
should always be performed at the patient's residence, and 
the recumbent position ordered for several days at least. 
The bowels may be kept open with small and repeated doses 
of magnesium citrate, to which a few drops of hydrocyanic 
acid may be added. The hot douche twice a day for a week 
is worth a trial. 

Pessaries are rarely of much benefit in this form of displace- 



ANTEFLEXION. 101 

ment. Thomas' anteversion pessary, with Playfair's modifi- 
cation, or Cutter's loop pessary, are the best. Where the 
abdomen is lax and heavy, an abdominal supporter, fitting 
snugly, and sustaining the pendulous mass, may be worn for 
a time. A simple supporter can be made from a piece of 
medium sole leather, soaked in warm Avater, and moulded to 
the form while wet. Covered with cloth, and fitted with 
broad tapes, it often proves more serviceable than the expen- 
sive belts sold by instrument makers. If a vulcanite pessary 
cannot be worn, on account of the irritation produced by it, 
she may use a wad of absorbent cotton or wool, saturated 
with glycerine. 

As a last resort, other remedies failing, a triangular piece 
of mucous membrane may be dissected from the vaginal wall 
in front of the cervix, and catgut stitches inserted, with a 
view to drag the cervix downward and forward, and in this 
way lift the fundus. 

ANTEFLEXION 

is a common displacement, and consists in a bending forward 
of the uterus, with the body leaning on the bladder and the 
neck in its natural position. In some cases, the womb is 
anteverted as well as anteflexed, and then the cervix is higher 
up than it should be. 

Anteflexions are most frequently congenital ; but they may 
be caused after puberty by subinvolution, atrophy of the 
uterine tissue at the junction of the corpus and cervix, con- 
stipation, and uterine tumors. 

There are few symptoms characteristic of this affection. 
When the flexion is extreme, the canal is more or less 
occluded, which necessarily obstructs the exit of the men- 
strual fluid, and leads to engorgement and dysmenorrhoea. 
Sterility almost invariably follows. Anteflexion is often 
complicated with endometritis, aggravating the distress at- 
tendant on that diseasp. A bimanual examination will gen- 
erally detect the nature of the displacement. The forefinger 



102 DISEASES OF WOMEN. 

of the left hand passes Into the sulcus, and feels the fundus 
in front of it, and two fingers of the right hand pressed down 
above the symphysis pubis communicate a sensation to the 
finger in the vagina. As pregnancy seldom occurs in ex- 
treme anteflexion there is less objection to using the uterine 
sound to verify the diagnosis. 

Treatment. — Apart from treating the complications, not 
much can be done in anteflexion. It must be borne in mind 
that the displacement is either congenital or is the final result 
of gradual changes extending over a long period of time, 
which weaken the uterine wall at the point of flexion. An 
intra-uterine stem pessary may be cautiously tried for a few 
hours daily, provided that the uterus will tolerate its pres- 
ence. In many cases it excites inflammation, and its use is 
by no means free from danger. Dr. Cutter's stem-pessary, 
with rubber tube attached to waist belt, succeeds in some 
cases. Care should always be taken to ascertain that the 
stem does not impinge on the roof of the fundus ; it should 
be half an inch shorter than the cavity. 

Especial attention must be paid to improving the general 
health by gentle outdoor exercise, daily sponge-baths, proper 
food, nervous tonics, and regular defecation. Laxatives and 
enemata are often needed as adjuvants in the treatment. 



CHAPTER XL 

PROLAPSUS, PROCIDENTIA, ELONGATION OF 
CERVIX, INVERSION. 

PROLAPSUS UTERI, 

or " falling of the womb," seems to be a necessary prelude 
to all forms of displacement. This term is applied to a partial 
descent of the uterus, with invagination or doubling of the 
vaginal walls. When the womb appears outside the vulva, 
with complete inversion of the vagina, it is called proci- 
dentia. 

At one time surgeons were not aware that the cervix may 
become elongated and hypertrophied, sometimes even, ap- 
pearing externally, without true prolapsus occurring. This 
state of things, the fundus remaining in place while the 
cervix protrudes from the vulva, was first pointed out by 
Huguier. True prolapsus most frequently takes place as a 
result of subinvolution after childbirth or abortion. It is also 
liable to occur after the menopause, following absorption of 
the packing (cellular tissue and fat) which helped to keep the 
womb in its place. When the perineum is ruptured during 
labor, prolapsus is very apt to follow at some future period. 
A spontaneous cure seldom takes place ; the tendency is from 
bad to worse, unless early attended to. 

Treatment . — This may be either palliative or radical. 
Rest in the recumbent posture, with long-continued hot-water 
injections (about four gallons at a sitting), followed by the 
insertion of a small muslin bag filled with tannin, alum, iron 
sulphate, or zinc sulphate, will help temporarily. Position is 



104 DISEiVSES OF WOMEN. 

of the greatest service. The patient, when resting, should lie 
on a hard lounge, with her hips and lower extremities raised 
higher than her shoulders. In this position an ounce of some 
astringent liquid can be retained in the vagina. Cotton or 
woollen wads saturated with glycerine also relieve congestion 
by draining the swollen tissues of serum. If the perineum is 
intact, and the vagina retains a certain' degree of elasticity^ a 
block-tin lever pessary may be inserted, care being taken not 
to distend the vagina unduly, and an examination should be 
made once a week to find out that the pessary is not doing 
mischief. After a variable length of time the patient should 
try to get along without it. 

If the perineum is ruptured, it should be restored by a sur- 
gical operation. If complicated with rectocele, a triangular 
piece of mucous membrane in the posterior vaginal wall may 
be removed with scissors and the surface drawn together 
with metallic sutures ; or, in some cases, a similar piece taken 
from the anterior surface will better answer the purpose. 
The patient must, of course, be confined to bed until the 
sutures have been removed and the wound has entirely 
healed. 

PROCIDENTIA UTERI 

is a comparatively rare affection. It is in reality a hernia, the 
vagina being inverted, with the uterus, a part of the bladder, 
and intestine included in the sac, which appears outside, the 
vulva. Procidentia may be partial or complete. If any part 
of the uterus protrudes through the labia it is called proci- 
dentia. Where the displacement has been of long standing 
the mucous membrane loses its characteristic appearance and 
becomes more like ordinary skin. The daily friction to which 
the tumor is subjected results in abrasion ; but the subjective 
symptoms are generally not as severe as we would expect in 
so formidable an affection. Leucorrhoea is always present. 
As antecedents, the pubic arch must be large and the peri- 
neum torn or relaxed ; and, when the procidentia is complete, 



PROCIDENTIA, ETC. 



105 



retroversion must also have previously occurred. Sometimes 
procidentia is caused by the growth of pelvic tumors, which 
crowd the womb outward. In most cases the descent of the 
uterus is preceded by a prolapse of the anterior vaginal wall, 
which includes a portion of the base of the 
bladder, and, when this is the case, dilata- 
tion of the ureters and pelves of the kidneys 
is sure to follow. 

Treatment, — If the mass is swollen, ab- 
raded, and tender, rest in bed for a few days 
or weeks, scarification, and the hot douche 
will help to reduce its size, and relieve the 
inflammatory tenderness. The patient is 
then placed in the knee-elbow position and 
the organ gently replaced. If an elderly 
woman, Dr. Cutter's ring- or cup-pessary will 
best answer the purpose of keeping it in position. If young 
or middle-aged, a block-tin lever pessary may be tried. 
When the abdomen is protuberant and flabby an abdominal 
supporter should be worn. The hot douche may be used 
every morning for half an hour, followed by mild astringent 
injections, or a small muslin bag full of tannin Inserted 
daily. 

HYPERTROPHIC ELONGATION OF THE CERVIX 




Fig. 27. 



may occur principally In that part of the neck which Is situ- 
ated above the vaginal attachment (supra-vaginal), or In that 
part which lies below the attachment (infra- vaginal), or the 
elongation may take place both above and below the vaginal 
junction. In most cases the lower portion of the cervix is 
also inverted, the os being patulous and the mucous mem- 
brane everted. Prof. Schroeder says : " The cervix should 
not be divided into two sections — an infra-vaginal and a 
supra-vaginal — but, in accordance with the different inser- 
tions of the anterior and posterior vaginal walls, into three 



io6 



DISEASES OF WOMEN. 




portions : a, that part of the cervix situated below the inser- 
tion of the anterior vaginal wall, designates the true infra- 
vaginal portion of the cervix ; c, that part situated above 
the insertion of the posterior vaginal wall, the true supra- 
vaginal portion ; while b represents the section between these 
two portions, being supra-vaginal in front and infra-va- 
ginal behind." Morgagni, Levret, 
and others were aware of the distinc- 
tion between elongation and true 
procidentia; but the knowledge had 
been forgotten, when Huguier again 
drew attention to it in 1859. 

Elongation is of more frequent oc- 
currence than procidentia. There are 
two forms of the affection — one found 
in women, married or single, who 
have never borne children, and the 
other in fruitful women after middle 
is a congenital malformation. When 
moderate in degree, and not procident, it may escape obser- 
vation for a long time. The elongated cervix acts as an irri- 
tant to the vagina, producing a muco-purulent leucorrhoea. 
When the hypertrophic elongation is excessive, the anterior 
part projects from the vulva, and resembles a penis so much 
as to have been mistaken for that organ, and the subject 
classed as a hermaphrodite ! 

In the other form, which may be called the acquired, 
inflammation and subinvolution play the principal parts. 
The fundus is sometimes fastened by adhesions, while the 
engorged cervix, from continuous deposit of plastic material, 
increases in length. After a time the cervix is grasped 
between the full bladder and loaded rectum and stretched 
by the tension. Finally, when the neck appears externally, 
the sphincter vaginae holds it firmly and the inner portion is 
stretched. Dr. Barnes calls attention to the fact that, ** when 
this condition has reached its extreme limit the cervix and 



Fig. 28. — After Schroeder. 

agfe. The first form 



ELONGATION OF CERVIX. 



107 



uterus almost Invariably measure exactly five Inches, that is, 
just double the normal length." In young or middle-aged 
women the hyperplasia keeps the cervix as thick or even 
thicker than natural ; but in old women the neck is stretched 
and thinned like a rubber tube. 

Treatment. — The only remedy for the congenital form is 
amputation ; and this is best effected by the galvano-cautery, 
Paquelin's thermo-cautery, or scissors. The patient is placed 




Fig. 29. — Paquelin's Thermo-Cautery. 

on her left side, in Sims' position, and a retractor of horn, 
ivory, or wood employed, instead of the metallic speculum. 
The cervix is firmly fixed with a suitable vulsellum, the plati- 
num loop applied, connection made with the galvanic bat- 
tery, and the loop slowly. tightened. There is Httle risk of 
hemorrhage if the operation is performed slowly. The e'cra- 
seur has been used for this operation, but its tendency ta 
drag in more tissue than is intended, makes it an unsafe 



I08 DISEASES OF WOMEN. 

instrument for this purpose. Even in the most skilful hands 
the peritoneal cavity has been unintentionally opened and 
serious risk incurred. Care must be taken to prevent clo- 
sure of the external os, by passing a sound frequently, or 
wearing a short intrauterine pessary for a month after the 
operation. 

The treatment of the second form is more difficult. If we 
conclude to amputate, great pains must be taken to dissect 
the uterine tissue from both bladder and rectum. The cervix 
is slit bilaterally, with strong scissors, for half an inch or less, 
and each flap cut off separately. Dr. Sims draws the mucous 
membrane over the stump, and stitches it down with silver- 
wire sutures, leaving a small oval opening in the centre.^ 
Catgut ligatures might be used instead of silver. 

If the patient object to a surgical operation, or if there are 
good reasons for not performing amputation, she should be 
kept in bed for a couple of weeks, during which leeches may 
be applied or the surface freely scarified, excoriations healed, 
the protruding cervix pushed up, and retained with a pad 
and elastic bandage. Pledgets of absorbent cotton saturated 
with tannate of glycerine, renewed every morning and even- 
ing, form the best application. When congestion and inflam- 
mation have been relieved, a Cutter's ring pessary may be 
applied. The thinned cervix is very apt to double up and 
form a flexion. 

Case XIII. — Mrs. Blank, a sprightly old lady, thin and 
wiry, who in her day had been a great worker, and who 
principally regretted the occurrence of prolapsus on account 
of its hindering her from active occupation, called at my 
office for advice. A bimanual examination showed that she 
was laboring under hypertrophic elongation of the cervix 
(supra-vaginal). It protruded from the vulva, to a small 
extent, in the erect posture, was much congested at its lower 

^ Sims' Uterine Surgery, p. 206. 



INVERSIO UTERI. IO9 

part, and slightly abraded. The sound passed five inches. 
The surface was freely scarified, and painted with tincture 
of iodine ; a cotton wad soaked in glycerine was pushed into 
the posterior cul-de-sac. She remained under treatment for 
nearly six months, the applications being made fortnightly at 
my office, and daily by herself at home. At the end of that 
time I applied a Cutter's loop-pessary, which she wore for two 
months continuously. I only saw her once after inserting 
the pessary. She expressed herself as perfectly satisfied with 
the result ; she was able to do her housework, and could walk 
several miles without inconvenience. 



INVERSIO UTERI 

is a turning of the womb inside out, like the finger of a glove, 
accompanied by prolapsus or even procidentia. When it fol- 
lows delivery, replacement is easy, if attended to at once ; 
but exceedingly difficult if delayed for a few hours. But in- 
version may possibly occur in a w^om^an who has never been 
pregnant, as the result of a sessile fibroid or a polypus 
attached to the fundus. The m.ere presence of a tumor 
causes enlargement of the womb ; pressure produces partial 
absorption of the fundus, followed by depression or dimpling ; 
the weight of the new growth increases the depression until 
the uterine walls grasp it and strive to expel it as a foreign 
body. At this stage of partial inversion mistakes are most 
liable to be made, for the inverted fundus feels like a fibroid 
tumor projecting into the cervical canal. In lean patients 
the fundal depression can often be felt above the pubis ; and 
the uterine sound, covered with an oiled tampon, may at the 
same time demonstrate the nature of the case and serve to 
push back the depressed fundus. But, in women whose abdo- 
minal walls are loaded with fat, few gynecological problems 
are more difficult to solv^ than this one. 

When the inversion is complete, or nearly so, the accom- 
panying prolapsus will aid us in making a correct diagnosis. 



no DISEASES OF WOMEN. 

% We note the absence of the os uteri, we see the peculiar 
appearance of the uterine mucous membrane, and, if we pass 
a silver catheter into the bladder, we can feel its point through 
the rectum, which we could not do if the womb were in its 
proper place. 

The ordinary predisposing cause of sudden inversion is 
inertia. The most prominent symptom is shock, which may 
prove so severe as to cause death in a few minutes. Shock 
is followed by fainting-fits, vomiting, and hemorrhage. When 
inversion occurs gradually, we have metrorrhagia, dysuria, 
dyschezia, nausea, dragging sensations in the back and pelvis, 
ending in anaemia. 

Treatment. — If detected at the time of its occurrence, noth- 
ing can be simpler than the reposition of an inverted uterus. 
The patient is first etherized. If the placenta remains wholly 
attached, an attempt may be made to return the protruded 
mass by gently pushing up one side of the fundus ; but, if 
this cannot be readily effected, peel off the placenta and 
push up one horn of the uterus, as before. The organ is 
steadied by the operator's other hand above the pubis. 

Chronic inversion at one time was set down as incurable. 
Dr. Gooch, in one of his lectures, says of the inverted uterus, 
** the art of man cannot restore it to its natural situation." 
But great progress has been made since then, and the treat- 
ment of this affection is one of the triumphs of modern sur- 
gery. The late Dr. Tyler Smith reduced an inversion of 
twelve years' standing in a few days, by continuous pressure 
on the fundus with an air-pessary. Prof. James P. White, of 
Buffalo, has reduced twelve chronic cases, one as early as 
1856. He employs a cup-shaped instrument to press against 
the fundus, and to the other end a spiral spring is attached, 
which rests against the operator's breast, and allows him to 
use both hands in aiding the reposition. Dr. Noeggerath, of 
New York, recommends a new method. "■ It consists in 
compressing the uterine body opposite to each horn [with 
a single finger] so as to indent one of these,- and thus offer 



INVERSIO UTERI, III 

to the cervical canal a wedge, which passes up, and is fol- 
lowed rapidly by the other horn and the whole body." The 
uterus should always be steadied above the pubis, and the 
cervix dilated. Dr. Emmet's method is as follows: *' He 
passed his hand into the vagina, and, while the fundus 
rested in the palm, the five fingers were made to encircle 
the portion within the cervix, as near as possible to the seat 
of inversion ; whilst the portion was thus firmly grasped it 
was pushed upward, and the fingers were immediately after- 
ward expanded to their utmost. This manipulation, with 
the aid of the other hand over the abdomen, was persevered 
in until the fundus had passed within the os uteri." 

The following interesting case occurred in the practice of 
Dr. CHfton E. Wing, Boston. 

Case XIV. — '* The patient was a native of Massachusetts, 
thirty-six years old. She was first married when nineteen, 
and to her second husband when thirty-three. Had four 
children by her first husband, all her confinements passing 
off well. Was hearty and able to be about her household 
duties up to the time of her fifth confinement (fourteen 
months before seen). She was attended by an 'irregular.' 
Was in labor forty hours from the time the waters broke, 
when she was delivered with instruments, a second physician 
being in consultation. Flowed awfully at the time. Stayed 
in bed five weeks. During this time, that is, till she was up 
on her feet,' her urine dribbled away continuously. When 
she got up, she found that, after being on her feet a short time, 
uterine flowing would set in, ceasing when she kept her bed 
a few days, only to reappear when she again left it. Two 
months after confinement she had a severe hemorrhage, flow- 
ing 'nearly to death.' Has flowed three-fourths of the time 
since. Dr. Bronson was. called in, diagnosticated an inverted 
uterus, and asked me tS/see the case with him. 

** The patient, a large, rather heavy woman, was found 
lying on a lounge. She was exceedingly anaemic. On intro- 



112 DISEASES OF WOMEN. 

ducing a Sims speculum, the vagina was found filled with a 
pretty firm, red, fleshy tumor, having a tendency to bleed. 
She Avas advised to come to Boston for treatment, which she 
did som.e weeks later. When she arrived (February 13, 
1879), she was flowing freely; Avas sent to bed, the foot of 
which was elevated, and after four days in this position, the 
flowing having meantime ceased, was put upon full doses of 
tinct. ferri chlor., and ordered copious hot-water vaginal injec- 
tions several times daily. These were continued five days, 
when the tumor was found much less tender, less congested, 
and showing very little tendency to bleed when handled. 

*' I had previously determined to treat the case by con- 
tinued pressure applied to the inverted fundus, and employed 
a common wooden stethoscope as a stem to go into the 
vagina and press upon the uterus, tying strong sheet-rubber 
over the open larger end ; the other end projected from the 
vulva. Pressure was obtained by using two pieces of com- 
mon elastic tubing passed between the thighs, where they 
were tied by the middle to the outside end of the stetho- 
scope, the ends being drawn tight and attached in front and 
behind to a waist-belt. I found that, by regulating the tension 
of these elastic bands, not only could the amount of pressure 
be easily controlled, but the direction of the force be perfectly 
managed. The sharp rim of the stethoscope was going to 
cut into the uterine tissue ; I therefore substituted a piece of 
wood of much the same shape, but solid, the upper end being 
a little concave. The evening of the second day there was 
evidently -some gain. The evening of the third day the 
patient felt a little restless. The pulse, which was at 96 
when the process began, ran up to 108. I gave her a one- 
fourth-grain dose of m.orphia, which was all the medicine, with 
the exception of the iron tonic, she received. She slept well, 
but was waked up in the middle of the night by feeling 
* something jump inside.' On examination in the morning, 
I found the uterus replaced, and the end of the instrument 
extending up into its cavity. The patient was kept in bed 



INVERSIO UTERI. II3 

for a few days, and the hot-water injections continued. She 
returned home a week later." 

If reduction cannot be effected by any means, as a last 
resort the womb may be amputated ; and this has accord- 
ingly been done in several cases, the patients recovering.' 



^ For articles on this curious and interesting subject, see the following : 
Trans, American Med. Assoc, for 1875. Paper by Dr. Bontecou. 
Trans. Ohio State Med. Soc. for 1865. Report by Dr. Sweeney. 
Amer, Jour. Med. Sciences, January and April, 1866. Papers by Dr. Emmet. 
Boston Gyn. Journ., Vol. II. : Removal of Inverted Uterus, by Dr. Brickett. 
Boston Med. and Surg. Journal, Vol. XIV. : Amputation of Uterus after Par- 
tial Inversion, by Dr. Parsons. 

Amer. Jour, of Obst., Vol. II., No. 2. Paper by Dr. Emmet. 
Ibid., Vol, II., No. 3. Paper by Dr. Thomas. 

8 



CHAPTER XII. 

UTERINE TUMORS. 

Uterine tumors may be conveniently divided into four 
classes, namely : 

1. Subserous fibroids, attached to the outer surface. 

2. Sicbmucoiis fibroids^ broadly adherent to the inner sur- 
face. 

3. Liter stitial fibroids, embedded in the muscular tissue. 

4. Polypi, attached by a pedicle to either surface. 

The first variety, subserous or subperitoneal, situated im- 
mediately beneath the peritoneal coat, whether sessile or 
pediculated, is not of much interest to the gynecologist, 
because, in most cases, it is practically incurable. To get at 
it, we would require to open the abdominal cavity, a proce- 
dure which would rarely be justifiable in such cases. 

The second or intra-uterine variety is almost invariably 
enclosed in a capsule, and is attached by a broad surface 
beneath the mucous membrane. Sometimes a portion of 
the covering is absorbed, and the tumor is expelled into the 
vagina by uterine contractions, as in labor. More frequently 
it requires to be removed by the surgeon. 

Interstitial fibroids are often incorporated so intimately 
with the muscular walls of the womb that their removal is 
very difficult. If enclosed in a capsule, the operation is more 
likely to succeed. 

All three varieties have a tendency to assume the globular 
form. Their structure is hard, almost cartilaginous, so that 
they creak under the knife. They consist of the same tissues 



UTERINE TUMORS. II5 

which constitute the normal uterine walls, with a preponder- 
ance of glistening connective tissue. They are subject to 
several kinds of degeneration. Sometimes cysts form inside, 
containing fluid, and they are then called fibro-cystic tumors. 
They are also subject to fatty and calcareous degeneration. 
They vary in size from that of a pin-head upwards. Nothing 
whatever is known about their etiology. Dr. J. H. Thomp- 
son says : " About eighty per cent, of those generally classi- 
fied as fibroid growths have occurred in colored women." ^ 
They certainly are found much more frequently in colored 
than in white women. 

Polypi are of different kinds. We meet with fibrous polypi 
similar in structure to those already mentioned, and mucous 
polypi of a gelatinous consistence. The former may be 
attached either to the outside or inside of the womb. Sub- 
mucous fibroids occasionally become converted into polypi 
during growth. Those of small size are eventually extruded 
into the vagina. Mucous polypi are generally attached to the 
inner surface of the cervix, and, on account of their extreme 
softness, are difficult to remove. They are sometimes quite 
vascular. 

Submucous, interstitial, and polypoid growths are all likely 
to give rise to debilitating hemorrhage. Sometimes a minute 
mucous polypus will cause an amount of bleeding altogether 
out of proportion to its size and the calibre of the vessels 
which supply it. Even subperitoneal fibroids, in some 
cases, are attended with excessive flowing. In general, 
fibroids (myoma) are not largely supplied with blood, and 
are of slow growth. When attached above the internal os, 
the whole organ becomes enlarged and dilated. Besides the 
metrorrhagia, the patient often complains of pain in the back 
and groins, leucorrhoea, dysuria, and anaemia. These growths 
are all of frequent occurrence. 

Treatment. — Mucous polypi are best removed by torsion 

' Report of Columbia Hosp. for Women, p. 112. 1873. 



ii6 



DISEASES OF WOMEN. 



with a staut pair of uterine forceps, made with short jaws and 
long handles. Most of the forceps in the market have the 
pivot too near the handles, so that they do not retain their 




Fig. 30. — Polypus Forceps. 

hold. They are also made so slender that the spring of the 
blades allows the object grasped to slip. 

Fibroid polypi may be removed with stout curved scissors, 
or, preferably, with the wire ecraseur. It is seldom that the 
resulting hemorrhage causes any trouble. To avoid risk, the 
remains of the pedicle may be touched with Monsel's styptic, 
in powder, or the cervix plugged with iron-cotton. If the 
polypus is attached above the internal os, it will be necessary 
first to dilate the cervix with a sponge-tent, and then remove 




Fig. 31. — Wire Ecraseur. 

it with the wire ecraseur. I have found a single annealed iron 
wire answer the purpose better than a wire-rope or steel 
piano-wire, formerly employed. It is well to leave a small 
piece of the pedicle, so as to avoid dragging in any portion 
of the uterine wall ; in other words, the wire loop should not 
be applied too near the attachment of the pedicle to the 
uterus. If the stalk is very thick, it may be first compressed 
with the ecraseur until strangulated, and then separated with 
scissors. There is less risk of bleeding if cut with scissors 
than with a knife. The ligature should never be employed. 
It is a fertile source of septicaemia. 

In many cases submucous (sessile) fibroids do not need to 
be interfered with. Their rate of growth is slow, and the 



UTERINE TUMORS. 



117 



patient may reach the menopause, when the natural tendency 
is toward atrophy. But, if the mass is large and produces 
disturbance by pressing on important organs, and more espe- 
cially when it gives rise to exhausting hemorrhages, our duty 
becomes plain to attempt its removal, and the best method 
is by enucleation. 

The first step is to sufficiently dilate the os with carbolized 





Fig. 32.— Sponge-tents. (From Munde's "Minor Gynecology," p. 244.) 



sponge-tents (made_ without gum, by the Bantock method), 
followed by a Barnes dilator. Then the capsule is seized 
with a stout vulsellum and incised with scissors 



Through 



Il8 DISEASES OF WOMEN. 

the opening thus made one or two fingers are inserted, and 
the capsule separated as high as they can reach, pressure 
being made over the pubis by an assistant. If the tumor 
is large, it may be necessary to use a Sims enucleator. It 
occasionally happens, as occurred in the following (personal) 
case, that after the tumor is entirely detached, it is too large 
to pass through the os, and must be cut into pieces in situ. 
This is best done with the wire ecraseur. The following 
account is abridged from an article by the author, in the 
Journal of the Gyticecological Society of Boston for February, 
1871 : 

Case XV.— Mrs. S. B., from Peabody, Mass. ; thirty- 
six years of age, married, and the mother of two children, 
the younger of whom was born eleven years ago, was brought 
to my office in Stoneham, July 19, 1870. Appearance anae- 
mic, much debilitated ; stomach irritable, with scarcely any 
appetite, and frequent nausea. During the preceding nine 
years she has been subject to copious hemorrhages, aggra- 
vated at the menstrual periods. On examination per vagi- 
nmn the uterus was found considerably enlarged ; the sound 
passed four and one-half inches. 

A sponge-tent was inserted July 21st, allowed to remain 
five hours, and a second tent inserted, which was removed 
next morning. On account of the extreme heat of the 
weather and the near approach of her menstrual flow, nothing 
more was attempted till July 29th, when a third tent was in- 
serted, removed after five hours, and replaced by an extra 
large tent, which was allowed to remain overnight. On its 
removal, the presence of a lobulated fibrous tumor, attached 
to the body of the womb, and especially to the posterior wall 
and fundus, could be distinctly felt. Dr. H. R. Storer was 
consulted, and agreed to see the patient on the following 
Tuesday. He was unfortunately prevented from attending 
by personal sickness. Drs. Sullivan, Abbott, and Stevens 
assisted. The patient was fully etherized, and a portion of 



UTERINE TUMORS. II9 

the capsule broken up by scissors and fingers. Several un- 
successful attempts were made to pass the chain of an ecra- 
seur around the base of the tumor. She rallied well (having 
been on the table three hours), and passed a good night. 

A week later, August 9th, the patient Avas again etherized 
in the presence of Drs. Storer, Sullivan, and Abbott. The 
cervix was fully dilated with a Barnes bag, but it soon con- 
tracted again. Dr. Storer incised the cervix, and he tried to 
pass the chain of an ecraseur above the tumor, but without 
success. At this stage. Dr. Ephraim Cutter arrived, and 
also made an unsuccessful attempt to pass the chain. For- 
tunately, he had brought with him a new instrument, capable 
of being attached to the large ecraseur, for operating in deep 
cavities. An oval loop of annealed iron wire was formed and 




Fig. 33. — Tubes for Ecraseur. 

passed into the womb by the side of the growth. The loop 
was then expanded and passed over the tumor by the aid of 
the new tube, finger, and a blunt-ended sponge-holder. Trac- 
tion was made, the finger following the wire until the section 
was completed. Still it could not be removed from the uterus 
on account of its bulk (being about as large as a man's fist), 
until cut into three pieces with the wire ecraseur. Even then 
it was with great difficulty that Dr. Storer finally succeeded 
in ** delivering" the two larger sections. 

During the operation, which lasted fully three hours, stimu- 
lants were occasionally administered. I drew off the urine by 
catheter at 5 and 8 o'clock P.M. ; at 1 1 P.M. she passed water 
voluntarily, nor did the catheter require to be used again. 
No untoward symptoms occurred during recovery. In less 



120 DISEASES OF WOMEN. 

than four weeks she returned home. Her appetite gradually 
improved. About five weeks after the operation, the men- 
strual flow set in, and was moderate in quantity. 

This patient was examined by me four years later. The 
uterus was of normal size, not prolapsed ; there had been no 
return of the hemorrhage, and she enjoyed moderately good 
health. I examined her again in 1880, and found the parts 
as before. During the ten years which have elapsed since 
the operation she has been able to perform the ordinary 
duties of a housewife. 

Case XVI. — Miss B., a resident of Concord, Mass., forty- 
three years old. Has been ailing for five years, during 
which time she has had many attacks of uterine hemorrhage, 
latterly increasing in frequency and severity. She has been 
attended by several regular physicians, none of whom ever 
asked to make a vaginal examination. I visited her at Con- 
cord, August 29, 1869. Found her in bed; appearance of 
skin corpse-like ; eyelids and lips almost bloodless. Could 
not turn in bed without fainting. Stomach irritable, and 
unable to retain solid food ; anorexia, insomnia, restlessness. 
I made a vaginal examination, which she readily consented 
to, and found a fibroid polypus, about two inches long, 
attached by a thick pedicle to the inner and posterior surface 
of the cervix uteri. Prescribed nutritive enemata and stimu- 
lants. 

September lOth. — With the assistance of Drs. Cutter and 
Barrett, I applied the chain ecraseur, and severed the pedicle 
in fifteen minutes. It is better to proceed slowly ; there is less 
risk of bleeding. In this case there Avas almost none. We 
gave a little ether toward the close of the operation, at the 
patient's request. The polypus was distinctly fibroid. She 
slept w^ell that night, and took plain food next day with a 
relish to which she had long been a stranger. Dr. Barrett, 
of Concord, now took charge of the case. 

Visited her again October lOth, and found her downstairs. 
There has been no return of the hemorrhage, and she has 



UTERINE TUMORS. 121 

steadily gained strength. Soon after she was able to do light 
work ; and is now married. 

Case XVIL — May 14, 1870. —The late Dr. Wm. F. 
Stevens, of Stoneham, asked me to see Mrs. K., a married 
lady, forty-five years of age. Before placing herself under 
his care, she had consulted an incompetent midwife, who 
told her that the frequent bleedings were due to the turn of 
life. And, indeed, it nearly proved to be *' the turn of life " 
on the wrong side, for when first seen by Dr. Stevens, who 
immediately detected the true state of affairs, she was seri- 
ously affected by the great loss of blood, so much so that her 
intimate friends believed her to be in consumption. A fibroid 
tumor, as large as a medium-sized Bartlett pear, occupied the 
vagina, and was attached to the posterior lip of the cervix. 

May 26th. — After suitable preparation, we applied the 
chain ecraseur, severed the attachment in ten minutes, with- 
out giving ether, and with very slight loss of blood. She 
made a good recovery. 

All cases, however, do not terminate so successfully. The 
following account of a (personal) case is abridged from the 
Journal of the Gyncecological Society of Boston for January, 
1870: 

Case XVIII. — Death front tetanus. — Mrs. G. I., Wo- 
burn, Mass., thirty-seven years of age. Twice married. 
Lived twelve years with her first husband, by whom she 
bore four children. Had lived two years with her second 
husband, by whom she had no children. Never miscarried. 
Was in the habit of using morphia per rectum. 

I attended her from February to May, 1868, for uterine 
disease. The womb was then enlarged and partially retro- 
verted ; the neck inflamed and ulcerated. Was again called 
to see her June 9, 1869. She complained of severe pains in 
back and loins ; but the principal trouble was a constant 
flow, mostly of blood, with an offensive odor. Inserted a 



122 DISEASES OF WOMEN. 

Sponge-tent, on removing which next morning could barely 
feel a hard growth, and advised a consultation with Dr. H. 
R. Storer, which she agreed to. Dr. Storer pronounced it a 
case of intra-uterine polypus. Again inserted sponge-tents 
June nth and I2th. After their withdrawal, the polypus was 
seized with vulsellum forceps, and extracted in several pieces 
by torsion. The operation was attended with considerable 
hemorrhage, which was finally arrested. June 19th all offen- 
sive discharge had ceased, and no remnant of the polypus 
could be felt by the finger. But, unfortunately, symptoms of 
tetanus set in June 21st, which gradually increased in sever- 
ity, and she died June 25th. The treatment consisted in the 
application of ice-bags to the spine, with the free exhibition 
of tincture of calabar bean, cannabis indica, and latterly chloric 
ether to relieve suffering. 

A post-mortem examination was made on the Monday 
following, assisted by Dr. Frisbie, of Woburn. Scarcely a 
trace of the polypus remained. A small cyst was found in 
the left ovary. The brain and spinal cord were not examined. 

Cases of traumatic tetanus following operations on the 
pelvic organs are of extreme rarity. Sir James Simpson 
only details one,^ and Dr. Thompson, of the Columbia Hos- 
pital, another.^ In the former case, the .polypus lay almost 
loose in the vagina, and was removed by slight traction with 
the fingers ; but on the ninth evening after its removal teta- 
nus supervened, and proved fatal in less than three days. 

The following is an abridged account of Dr. Thompson's 
case : 

Case XIX. — M. S., aged twenty-three, admitted Janu- 
ary 13, 1868. Married when nineteen years of age; has 
given birth to two children. Her general health has been 

^ Obst. and Gyn. Works of Sir James Y. Simpson, p. 570. 
I "^ Report of Columbia Hospital for Women, Washington, D. C, p. 102. 



UTERINE TUMORS. 123 

bad. For the two preceding years her menstrual periods 
have been irregular, and there has been a constant sanguineo- 
purulent discharge from the vagina. Skin of a dirty, waxen 
hue, lips almost colorless, and face bloated. The vagina was 
relaxed, uterus low down, and os patulous, through which 
the sound passed readily to the extent of four and three- 
fourths inches. A small polypus could be seen about half 
an inch within the cervical canal. A medium-sized sponge 
tent was introduced without difficulty, and a suppository con- 
taining half a grain of morphia ordered to be placed in the 
rectum if the patient should experience much pain. 

She suffered severely during the night. The suppository 
was used, and forty drops of Magendie's solution administered, 
but with little effect. The tent was removed with some diffi- 
culty, having been held firmly by the internal os. Next 
morning she complained of oppression about the epigastrium 
and stiffness in the back of the neck. Had not slept since 
the tent was introduced. There was difficulty in opening the 
mouth and in swallowing. Respiration labored, pulse lOO, 
temperature 104°. Ice was applied to the spine, and the 
morphia repeated ; in the evening, ext. cannabis indica, in 
half-grain doses, was ordered to be given every two hours. 
She died two days later. 

Dilatation of the cervix beyond the inner os (see p. 69) is 
an efficient remedy for uterine hemorrhage. 

Dr. Ephraim Cutter, of New York, employs electrolysis in 
large fibroid tumors attended with hemorrhage and pain. 
Two long stout needles are inserted into the tumor (generally 
through the abdominal wall) and a powerful galvanic current 
passed through the growth for a few minutes. I have seen 
several of his patients in whom severe pain was allayed, 
hemorrhage arrested for years, the tumors reduced in size, 
and the general health much improved after electrolysis. 
Sometimes the operation requires to be repeated two or three 
times. 



CHAPTER XIIL 
OVARIAN TUMORS. 

History. — No department of gynecology has developed so 
rapidly as this one. Ovariotomy was first performed by Dr. 
Ephraim McDowell, of Kentucky, in 1809, He operated 
thirteen times, with eight recoveries. The late Washington 
L. Atlee, of Philadelphia, operated for the first time in 1844 
unsuccessfully. Since then he has had 387 cases, of whom fully 
seventy per cent, recovered. Dr. Gilman Kimball, of Lowell, 
Mass., performed his first operation in 1855 ; since that time 
to the present (1880) he has operated 250 times. Dr. Walter 
Burnham, of Lowell, has operated 225 times. The late Pro- 
fessor Peaslee, Drs. Sims, Emmet, Dunlap, R. H. Storer, J. R. 
Chadwick, John Romans, and a host of others, have per- 
formed the operation many times. No major surgical opera- 
tion has ever been combated so fiercely as this one. Prof. 
Peaslee says that when he read his monograph on the subject 
before the New York Academy of Medicine, in June, 1864, 
there was not another surgeon in the city to defend the 
operation. A celebrated Philadelphia professor, in his pub- 
lished lectures, invoked the law to arrest Dr. Atlee in the per- 
formance of the operation. 

Dr. Chas. Clay, of Manchester, deserves the credit of giv- 
ing the original impulse to ovariotomy in Great Britain. His 
first operation was performed in 1842, and was successful. 
Up to the end of 187 1 he had operated 250 times, with nearly 
seventy-three per cent, of recoveries. 

But to Mr. T. Spencer Wells, of London, and Dr. Thomas 
Keith, of Edinburgh, belong the distinction of being the 



OVARIAN TUMORS. I25 

most successful operators in our day. Mr. Wells commenced 
his remarkable career as an ovariotomist in 1858 ; during the 
first three years he only operated on ten cases. Since 1858 
up to August, 1880, he has operated 1,000 times. Of his first 
500 cases, 373 recovered. Of a series of 100 cases in 1878, 83 
recovered. Dr. Keith performed his first ovariotomy in 
1863. Since then, up to July, 1878, he has operated 273 
times. Of the last 100 cases 93 recovered. 

Pathology . — Ovarian tumors may be classified under four 
heads, namely : monocystic, polycystic, dermoid, and can- 
cerous. The greater number of ovarian tumors are cystic, 
and contain fluid which readily flows through a small canula. 
They constitute a cystic degeneration or dropsy of the ovary. 
So far as is known, the origin of all ovarian tumors is con- 
genital. Attempts to trace the original start of cystoma to 
repressed sexual desire and other fanciful causes are not 
borne out by statistics ; at least, as large a number of fruitful 
married women as of unmarried and sterile women being 
affected. 

Monocystic or unilocular tumors are the simplest in struc- 
ture, and the easiest dealt with. They consist essentially of 
Graafian sacs unduly distended, several of which have coa- 
lesced during growth. Cysts may also form in the stroma or 
connective tissue of the ovary. Such tumors seldom inflame 
or contract adhesions to the neighboring organs. The fluid 
in monocysts is bland and limpid, of a pale straw color, and 
contains albumen, cholesterin, epithelial scales, inorganic 
salts, and a peculiar granular cell. Dr. Drysdale says that 
" the latter is generally round, but sometimes oval, very deli- 
cate, transparent, and contains a number of fine granules, but 
no nucleus. The size most commonly met with is that of a 
pus-cell. The addition of acetic acid causes the granules to 
become more distinct, while the cell becomes more transpar- 
ent." Mr. J. K. Thornton, Surgeon to the Samaritan Hos- 
pital, London, has recently pointed out that "in addition to 
those cells of Drysdale, which are common only in simple or 



126 DISEASES OF WOMEN. 

innocent ovarian tumors, in malignant tumors we find char- 
acteristic groups of large pear-shaped, round, or oval cells." 
Ovarian fluids, as a general rule, contain no fibrin. Ova have 
been found in many small cysts not larger than a cherry. 
This confirms the theory of their origin from Graafian vesi- 
cles. Pus or blood is not unfrequently found in the fluid 
drawn ofi* at a second or subsequent tapping. 

Diag7iosis, — The greatest improvement connected with 
ovarian tumors has been made in their more accurate diag- 
nosis. When Mr. Lizars, of Edinburgh, operated in 1823, 
but little was known on the subject, and he actually opened 
the peritoneal cavity only to find that no tumor of any kind 
existed 1 The supposed ovarian tumor was merely an accu- 
mulation of fat under the skin of the abdomen, and of gas in 
the intestines. Mr. Lizars also operated three times in 1825. 
Two of the tumors were not removed, on account of adhe- 
sions ; one of these patients recovered, and at her death, twenty- 
five years later, an autopsy was made, and it was ascertained 
that the tumor w^as a uterine fibroma, both ovaries being 
normal. Contrast this with the record of Dr. Keith, who dur- 
ing his whole career has never made an erroneous diagnosis. 

Ovarian tumors require to be distinguished from i, ascites ; 
2, pregnancy; 3, uterine fibroids ; 4, intestinal affections. 

In ascites, the fluid gravitates according to the position of 
the patient. In the recumbent posture, percussion gives us a 
dull sound at each side and resonance in front ; while these 
phenomena are reversed in ovarian dropsy, the fluid being 
confined in a sac, percussion gives us a dull sound in front, 
and resonance on the flanks. Ocular inspection shows us an 
ovarian tumor bulging more in front, lower down, and more 
to one side ; in ascites the sweUing is more symmetrical. 
The superficial veins are more frequently enlarged in ascites. 
Ascitic fluid contains true albumen ; ovarian fluid is distin- 
guished by the presence of paralbumert (which is redissolved 
or rendered transparent by boiling in strong acetic acid) and 
the granular cell. In ascites fluctuation is readily detected 



OVARIAN TUMORS. 12/ 

by a vaginal examination (Douglas' cul-de-sac) ; in ovarian 
dropsy not so readily, and sometimes not at all. The swel- 
ling of ascites may be temporarily relieved by purgatives and 
diuretics ; ovarian dropsy is never reduced by such treat- 
ment. 

Normal pregnaiicy could scarcely be mistaken for an ova- 
rian tumor by a practitioner of moderate skill. But in extra- 
uterine pregnancy the diagnosis would be more difficult ; and 
in those rare cases where pregnancy is associated with the 
presence of ovarian dropsy, the diagnosis is still more prob- 
lematical. When a tumor has existed more than ten months, 
we may be pretty certain that it is not a case of pregnancy. 
If the swelling is central, hard, increasing slowly in size ; if 
menstruation is arrested ; if the anterior vaginal wall is 
stretched like a drumhead ; if the vagina has a dusky, port- 
wine color ; if the cervix uteri is shortened and oedematous ; 
if the breasts are enlarged, and the areolae surrounding the 
nipples are dark and studded with follicles ; and especially if 
the pulsations of the fetal heart can be heard — we know that 
the woman is pregnant. 

It is possible that a patient may be pregnant and the sub- 
ject of an ovarian tumor at the same time. Mr. Spencer 
Wells gives the details of ten cases where this occurred in 
which he operated, and nine of them recovered. 

Uterine fibroids sometimes attain a large size, and where 
cystic degeneration has taken place it is often difficult to dis- 
tinguish them from ovarian tumors. If pregnancy be ex- 
cluded the uterine sound will help to clear up the diagnosis. 
Interstitial growths are more easily diagnosticated than those 
which are subserous or pedunculated. Uterine tumors are 
generally slower in their growth than ovarian. The former 
are also more frequently attended with metrorrhagia ; they 
increase in size at the menstrual periods, and are less mov- 
able than those of the ovary. Fibrocystic growths are best 
recognized by aspiration. The fluid contained in them coagu- 
lates spontaneously on exposure to the air in a shallow vessel. 



128 DISEASES OF WOMEN. 

Various intestinal affections, such as tympanites, indurated 
and hypertrophied omentum, fecal accumulations, and can- 
cer have been mistaken for ovarian tumors. Sir James 
Simpson states that no less than six cases have been put on 
record where the abdomen was laid open with the view of re- 
moving an ovarian tumor in patients whose most grave dis- 
order was only tympanitic distention of the intestines. Tym- 
panites gives a clear resonant sound on percussion, and there 
is absence of fluctuation. Omental growths give a semi- 
resonant sound on percussion and seldom attain a large size. 
Fecal accumulations maybe recognized by the doughy sen- 
sation communicated to the examining finger, and of course 
may be entirely removed by injections and laxatives. Can- 
cer affects the constitution in such a marked manner that it 
can readily be recognized in most cases, especially when 
other organs are involved. 

In addition to these sources of fallacy, we may have oedema 
of the abdominal walls, obesity, renal cyst, splenic cyst, he- 
patic cyst, retained menses, or distended bladder, all of which 
have been individually mistaken for an ovarian tumor. Fat 
can be lifted between the fingers and thumb. Renal cysts 
are generally behind the intestines, whereas ovarian cysts 
are commonly in front. The discovery of intestine in front 
of a doubtful tumor should lead to careful examinations of 
the urine. Phantom tumors disappear when the patient is 
fully anaesthetized. They are not caused by collections of gas 
in the bowels ; but may depend on some abnormal contrac- 
tion of the diaphragm, which pushes the bowels downward, 
or a peculiar contraction of the recti muscles may simulate an 
abdominal tumor. Before operating, the bladder should al- 
ways be emptied by a catheter, and in this way a distended 
bladder cannot be mistaken for an ovarian tumor. 

At one time much attention was paid to the detection of 
abdominal adhesions. In our day, Mr. Wells and the best 
operators everywhere practically ignore this drawback. But 
if adhesions exist low down in the pelvis, and can be detected 



OVARIAN TUMORS. 1 29 

beforehand, the operation should not be attempted. " These 
pelvic adhesions may be always suspected when the mobility 
of the uterus is considerably restricted." 

Treatment. — Medicine is powerless in this disease. Chlo- 
rate of potass and oxide of gold have both been credited with 
cures, and hydragogue cathartics have been used without 
stint. But apart from the rational use of remedies to allay 
pain or improve the general health, the administration of 
drugs always does harm both to patient and practitioner. 

Tapping. — As a means of temporary relief, or as an aid to 
diagnosis, tapping may be resorted to. Some diversity of 
opinion still prevails as to the propriety of tapping a patient 
with ovarian dropsy. It has been alleged that it causes ad- 
hesions, and is a dangerous operation ; ^nd if we follow the 
old clumsy method, with the patient sitting in a chair, per- 




FiG. 34. — Syphon Trocar. 

haps it is dangerous. But if the tumor be a monocyst, and 
the operation properly performed, the danger is slight. In 
polycysts and dermoid cysts the risks are much greater. 

The patient should be in bed, lying on her side near the 
edge, the abdomen projecting. Mr. Chas. Thomson's sy- 
phon trocar, as modified by Mr. Wells, is the best. No air 
is admitted, and the fluid is carried into a pail at the bedside 
without wetting the patient. The instrument should be in- 
troduced so " that the point passes into the fluid at a lower 
level than the commencement of the [rubber] tube." The 
bladder should previously be emptied by a flexible catheter. 
A slight incision is made by a scalpel in the linea alba, as low 
down as may be reckoned safe, avoiding hard portions of 
the tumor, large superficial veins, and adherent intestine, and 
9 



130 DISEASES OF WOMEN. 

the trocar thrust into the sac. In the best form of the instru- 
ment the trocar itself is hollow, and one-half of the cutting 
edge is purposely left blunt, so as to avoid punching out a 
piece of the sac. Dr. Emmet recommends that tapping 
should be performed with Dr. Dieulafoy's aspirator. Ova- 
rian fluid will readily flow through a No. 3 needle ; and with 
this apparatus the risk of wounding blood-vessels is reduced 
to a minimum. 

As a general rule, the cyst refills after tapping ; but there 
are several cases reported by Mr. Wells ^ where a radical cure 
was effected by a single tapping. Dr. Atlee also gives the 
details of three cases, in two of which the fluid did not reac- 
cumulate for twenty years, and in the other there was no 
return of the disease for six years. ^ It is probable that many 
similar cases reported by /less competent observers were cysts 
of the broad ligaments, in which tapping almost always works 
a permanent cure. 

Boinet strongly advises the injection of single cysts with 
iodine after tapping. He has performed the operation more 
than a thousand times. In polycysts and dermoid cysts this 
method is unavailing, and even more risky than ovariotomy 
itself. The only other cases in which it is justifiable are those 
in which inflammation and suppuration of the contents of the 
cyst have occurred, and, on account of pelvic adhesions, 
ovariotomy cannot be safely performed. For this purpose a 
weak solution of iodine in potassium iodide (iodine, 3j. ; po- 
tassium iodide, 3ij. ; water, sijss.) may be used as a disin- 
fectant, efficient drainage being at the same time attended 
to. For eff"ecting drainage, a straight or slightly curved glass 
tube, perforated for two inches with many small holes, and 
furnished with a shoulder to prevent its slipping into the ab- 
domen, is inserted into the pelvis. It should be large enough 
to allow a No. 8 flexible catheter to pass through ; and, so 

^ Diseases of the Ovaries, p. 271. 

^ Diagnosis of Ovarian Tumors, p. 155. 



OVARIAN TUMORS. 131 

long as the discharge is fetid, injections of a warm solution 
of potassium permanganate may be used every two hours, or 
oftener. 

OVARIOTOMY. 

But the cases are few and far between where merely pallia- 
tive measures are advisable. The great remedy for ova- 
rian dropsy is extirpation of the cyst — that is, ovariotomy. 
When no adhesions exist, and the tumor is monocystic, the 
operation is a simple one : when adhesions are strong and 
numerous, or where the tumor is polycystic or dermoid, the 
operation may turn out to be one of the most formidable in 
surgery, requiring not only the greatest coolness and presence 
of mind on the part of the surgeon, but also the skill which 
extensive experience alone can confer. 

Having fully satisfied ourselves that the patient has an 
ovarian tumor which can probably be removed, and guarded 
against mistake by calling an expert in consultation, the pa- 
tient being willing and anxious to be relieved from her bur- 
den, the next point is to ascertain whether she is in the best 
possible state for the performance of the operation. Experi- 
ence proves that a woman in robust health is more likely to 
succumb than one who has been some time an invalid, and 
whose health is beginning to break down. But, on the other 
hand, it is not advisable to wait too long ; that is, till the 
powers of life have become so undermined that there is not 
strength enough left to withstand the shock of the operation. 
As long as the patient can walk a mile comfortably, go up 
two flights of stairs without sitting down on the way, and 
is not harassed by pressure on the bladder or other important 
organ, it is better to wait, unless there are special reasons to 
the contrary. Dr. Keith says, " I prefer operating when the 
tumor is large, and when the patient has suffered a good 
deal." 

When we decide to operate, it is well to require the patient 
to remain in bed for two days beforehand, so as to accustom 



132 DISEASES OF WOMEN. 

lier to the irksomeness of confinement. The bowels must be 
freely evacuated on the morning of the operation. The early 
part of the afternoon is the best time to operate. This allows 
the patient the chance of a good night's rest, a simple break- 
fast, and plenty of time to make all necessary arrangements. 
With a view to prevent nausea the patient may suck small 
pieces of ice for two hours before being etherized. A clear 
bright day is best ; and it would be advisable to postpone the 
operation for a day or two if the wind is northeast. The in- 
struments needed are : 

A stout scalpel. 

A broad hernia-director. 

Trocar and tubing. 

Torsion-forceps, from four to t'wenty pairs. 

Probe-pointed scissors. 

A clamp. 

A curved blunt needle in handle. 

Sims' tenaculum. 

Nelaton's vulsellum. 

Needles. 

Carbolized silk ligatures. 

The trained nurse should furnish two wooden pails, a fan, 
four flannel bags filled with hot salt, hot and cold water, a 
small tub, and sixteen fine sponges, each as large as the 
closed fist, thoroughly freed from sand and other impurities. 
All the instruments should be kept immersed in a warm so- 
lution of carbolic acid (one to twenty) in shallow trays. The 
sponges are dipped in another portion of the same solution 
and wrung out. The operator and his assistants (four in 
number) wash their hands in a similar solution before com- 
mencing work. Stimulants (brandy, ammonia), and a hypo- 
dermic syringe charged with brandy or ether, should be 
within easy reach. A small electro-magnetic battery may 
also be kept in readiness. Long strips of newly made adhe- 
sive plaster, absorbent cotton, towels, styptic, and a flannel 
bandage fitted with buckles and straps will all be needed. 



OVARIAN TUMORS. 1 33 

Paquelin's thermo-cautery, or some efficient substitute, may 
be required to sever adhesions or arrest persistent hemor- 
rhage. 

A strong kitchen table, covered with blankets, can be used 
as an operating table. It should be placed so that the light 
will fall on it diagonally. A bed is not at all suitable. The 
patient's abdomen is covered with a thin sheet of rubber 
cloth with an oval opening eight inches long by six inches 
wide in the middle. This opening is coated all round with 
adhesive plaster, so that it may stick to the skin. Before ap- 
plying it, the skin should be washed with soap and water, 
and well dried. 

The patient is then given an anaesthetic. Mr. Wells uses 
bichloride of methylene, or rather a mixture of that fluid 
and alcohol diluted with ninety-six to ninety-eight per cent, 
of atmospheric air. He employs Dr. Junker's inhalation ap- 
paratus. Dr. Keith uses sulphuric ether. Dr. Marion Sims 
has employed nitrous oxide gas. Chloroform is objection- 
able, for two reasons : it is not as safe as ether ; and it is 
more likely to excite nausea and vomiting, a result specially 
to be avoided after making a large opening in the abdominal 
walls. Ether, therefore, is the anaesthetic I prefer. No spe- 
cial apparatus is needed to administer it. A hollow sponge 
in a felt cone, or wrapped in a towel, answers every purpose. 
Mr. Wells straps the patient's knees to the table, and secures 
her hands with two strips of bandage. This is to dispense with 
extra assistants. She is covered with a blanket below the ex- 
posed abdomen, and a woollen shawl over the chest. The urine 
is drawn off with a catheter. Carbolic acid spray, generated 
by a steam atomizer, is thrown over the abdomen by some 
operators ; but the advantage to be gained by doing so is 
questionable. Dr. Keith has abandoned the spray after a 
long trial. 

The abdomen is generally tense. An incision four inches 
long is made with a scalpel (using the point) through thelinea 
alba, beginning about two inches from the symphysis pubis. 



134 DISEASES OF WOMEN. 

This incision may be afterward extended two inches upward 
and one inch downward, if necessary. If she has been re- 
cently tapped, so that the abdominal walls are lax, the skin 
may be lifted up between two fingers and thumb, and trans- 
fixed Avith a bistoury. If it can be avoided, the incision 
should not reach the umbilicus ; and if absolutely necessary 
that it extend above the navel it is better to make a detour 
by carrying it to the left side, avoiding the umbilicus itself. 
Before opening the peritoneum, all bleeding vessels should 
be closed either with torsion forceps (which are fastened by a 
catch and left on for a time) or by ligature. The peritoneum 
is then raised with a tenaculum, carefully opened with one or 
two horizontal touches of the scalpel, the broad director in- 
serted, and the peritoneum divided with a probe-pointed bis- 
toury or scissors. This exposes the white glistening cyst, 
into which the trocar is plunged and the fluid evacuated. If 
there are no adhesions the tumor is gradually extracted. If it 
turns out to be multilocular, the remaining cysts are suc- 
cessively emptied. The surgeon's hand is then gently in- 
serted between the cyst wall and the peritoneum to search 
for adhesions, which, if present, are carefully separated, and 
the cyst withdrawn. The principal assistant holds up the 
abdominal wall, " keeping the edges of the wound together. 
He passes the middle finger inward under the umbilicus, 
and the forefinger to the right and the thumb to the left of 
the wound, holding the edges closely together as the tumor 
comes out of the wound." This is to prevent the intestines 
from rolhng out. 

The next step is to secure the pedicle. There are several 
ways of doing this. Some prefer the clamp, others the liga- 
ture ; much must depend on the peculiarities of each case. 
If the pedicle is long enough, and not too broad or too thick, 
it may be fastened with a clamp at the lower angle of the 
wound. When one part of the pedicle is thinner than an- 
other, it is well first to pass a silk ligature around it before 
applying the clamp. Great care must be taken not to in- 



OVARIAN TUMORS 



135 




Fig. 35.— Wooden Clamp, plain. 




Fig. 36.— Wooden Clamp, curved. 



136 DISEASES OF WOMEN. 

elude anything else but the pedicle in the clamp — a ureter or 
piece of intestine, for instance. The tissue which projects 
beyond is sprinkled with dry persulphate of iron/ 

If the pedicle is short, broad, or thick, it Avill be better to 
trust entirely to hgatures, which are generally cut short and 
left in the pelvic cavity. A long, blunt-pointed needle, with 
a double eye, threaded with stout carbolized silk, is pushed 
through the pedicle, which is securely tied in two or more por- 
tions before the cyst is cut off, at least half an inch from the liga- 
tures. Lymph is thrown out, and the short ends of the thread 
are either encysted or absorbed. Dr. Clay prefers to leave 
the ends of the ligatures hanging out at the lower angle of 
the abdominal wound. In a few cases other operators have 
made an opening into the vagina through Douglas' cul-de- 
sac, and passed the ligatures through. The best way, how- 
ever, is to cut them short, and leave them in the pelvis. 

The late Mr. I. Baker Brown first employed the actual 
cautery to sever the pedicle in 1864, and invented a cautery- 
clamp with an ivory shield for that purpose, which is still in 
use. Mr. Spencer Wells in several cases "cut off the cyst, 
and then with a druggist's spatula, well heated and used 
slowly, burned the portion of the pedicle between the two 
blades of the clamp." He uses a talc shield, which is the 
best non-conductor of heat known. Paquelin's thermo-cau- 
tery could be used to divide the pedicle, and it is the best 
cautery to arrest hemorrhage from oozing surfaces, and sever 
adhesions. Chassaignac's ecraseur has been used to divide 
the pedicle with good results. Dr. Miner, of Buffalo, first 
practised enucleation of the pedicle in 1869. He has since 
employed this method several times successfully. 

^ The clamp is not as often used as formerly. But in some cases it is of use 
temporarily to control hemorrhage, and in others it may be advantageously sub- 
stituted for the ligature. The high price of an instrument so seldom used induced 
the author to make a wooden clamp (shown in the engravings), which almost any 
mechanic could furnish at the price of one dollar, or less. These clamps, differ- 
ent sizes, can be procured of Messrs. Codman & Shurtleff, Boston. 



OVARIAN TUMORS. 137 

Whichever method is adopted, and every case must be 
decided according to its own pecuHarities, the surgeon then 
proceeds to examine the surfaces from which adhesions have 
been separated, securing bleeding vessels by torsion or liga- 
ture, and arresting oozing by free exposure to the air or by 
sponges dipped in Jiot water. He should also look at the 
other ovary to find out whether it is healthy or not. If seri- 
ously diseased it ought to be removed ; but if only slightly 
affected it is better to let it alone. The peritoneal cavity 
must be mopped out with soft sponges until thoroughly 
clean. No clots, fluid, ragged scraps of omentum,* or any 
extraneous matter, should be left. This ** toilet of the peri- 
toneum " is of the gravest importance. A large flat sponge 
is then slipped in over the bowels, and the wound in the 
abdominal wall sewed up. This is best done by means of 
strong Chinese black silk, each thread about eighteen inches 
long, threaded at each end with a medium-sized glover's 
needle. Each needle is introduced from within outward, 
mcliiding tJie peritoneicin^ about half an inch apart. The 
assistant takes charge of each suture as it is inserted, drawing 
the lips of the wound together. When the whole number 
required have been inserted, the lips are separated sufficiently 
to remove the flat sponge (which receives drops of blood 
from passing the needles), and to ascertain that no blood, 
serum, sponge, or forceps have been left in the abdominal 
cavity. The stitches are then tied. The sponges and forceps 
should be counted before and after the operation. 

The skin is then cleansed and dried, the rubber cloth re- 
moved, the wound covered with absorbent cotton, over which 
long strips of new adhesive plaster (going two-thirds of the 
way round) are applied ; and the whole abdomen is supported 
by a close-fitting flannel bandage. The patient is then car- 
ried to bed, kept on her back, the knees supported by a pillow, 
and covered with new blankets ; hot salt-bags placed near 
her ; the room darkened, kept moderately warm, and well 
ventilated ; and nobody save the nurse and physician admitted. 



138 DISEASES OF WOMEN. 

The after-treatment is of the greatest possible importance, 
yet it can be summed up in a (ew words. The nurse uses a 
flexible catheter to draw off the urine once in four hours, or 
oftener if needed, during the first week. The patient may 
have ice-pills almost without stint ; sips of hot milk (not 
boiled) occasionally ; and well-boiled flour porridge after the 
first day. Faintness is relieved by champagne wine or bot- 
tled cider in repeated sips, or by rapid fanning ; pain by 
hypodermic injections of morphia (one-eighth of a grain) or 
opium suppositories (one grain). Enemas of beef- tea or 
chicken-broth are sometimes serviceable. Should the urine 
become smoky and scanty, depositing urates abundantly, 
iced lithia water is the best remedy. Flatulence is relieved 
by passing a large elastic catheter into the rectum for several 
inches. An enema of quinine and laudanum has been recom- 
mended for the same purpose. 

If all goes well, and the dressing remains dry, it need not 
be disturbed till the morning of the third day. The wound 
should afterward be dressed daily. Cut the adhesive plaster 
about two inches from each side of the wound, and replace 
with fresh pieces attached to what has been left. The stitches 
may be removed on the fourth day. The bowels do not re- 
quire to be relieved for eight or ten days ; an enema of luke- 
warm soapsuds may then be administered. The abdomen 
should be supported by broad strips of adhesive plaster for at 
least two weeks after the stitches have been removed. A 
well-fitted flannel bandage, with straps, must be worn for six 
months or longer. 

But sometimes unfavorable — it may be dangerous — symp- 
toms supervene. There are four great roads which lead to 
death after ovariotomy. They are : shock, hemorrhage, 
peritonitis, and septicaemia. 

Not many patients die from shock. A hypodermic injec- 
tion of brandy or ether acts promptly. Brandy and beef- 
tea may be given by the mouth or rectum. Bags of hot salt, 
wrapped in hot flannel, are used to promote warmth. Dry 



I 



OVARIAN TUMORS. 139 

hot flannels are wrapped round the feet, and the patient lies 
between warm fleecy blankets, not between sheets. Vomit- 
ing is sometimes a very troublesome symptom. Ice-pills, 
iced champagne wine (in sips), hydrocyanic acid in small 
doses, rapid fanning, or a mild sinapism over the stomach, 
may control it. Death from shock usually occurs within 
twenty-four hours after the operation. Shock may be per- 
petuated by pouring in stimulants too rapidly or by giving 
doses too large. 

Hemorrhage, if it occurs at all, is likely to show itself 
within the first twenty-four hours. It may come from the 
pedicle, owing to ligatures slipping off. More frequently it 
proceeds from vessels ruptured in separating strong adhe- 
sions. If the vessels can be found, the safest way is to tie 
them securely (three knots) with silk thre'ad. Sometimes a 
minute quantity of Monsel's styptic in powder, applied with 
the finger-tip, will stop the bleeding. A silver probe coated 
with molten lunar caustic may be tried for minute points. 
Paquelin's thermo-cautery answers very well ; or, if not at 
hand, a red-hot knitting needle (heated in the flame of a 
spirit lamp) will serve the same purpose. If hemorrhage is 
profuse, it is better to cut the stitches and make a thorough 
exploration. Perfect rest and quietude are of course essen- 
tial. 

Acute peritonitis is a frequent cause of death. It may 
occur from the first to the fourth day, and is recognized by 
pallor of the cheeks, headache, anxious expression, tender- 
ness on pressure, a small, rapid pulse, and rise of temperature. 
It is not generally preceded by a chill. If much blood has 
not been already lost, leeches should be applied. Small doses 
of calomel, followed by moderate doses of opium frequently 
repeated, are serviceable in the early stage. Acetate of am- 
monia, largely diluted, may be given as a drink. Digitalis 
in small doses hourly is sometimes useful. Some practitioners 
prefer veratrum viride in the same way. When the disease 
is limited to the pelvis, poultices may be put on. • 



140 DISEASES OF WOMEN. 

There is a low (asthenic) form of peritonitis which sets in 
after the eighth day, marked by tympanites and vomiting of 
a dark fluid Hke coffee-grounds. This form does not bear 
depletion. Mr. Spencer Wells derived great benefit in one 
case of extreme tympanites by employing faradization. In- 
jections of warm spearmint or ginger tea are useful to relieve 
flatulence. Tinct. mur. fer., twelve-drop doses, in some aro- 
matic mixture, may be tried. 

Septicaemia does not usually occur earlier than the fourth 
day, and frequently as late as the eighth. The symptoms are, 
dry, coated tongue, loss of appetite, insensibility to pain, 
high fever, great debility, and a tendency to stupor. If 
fluid has accumulated it can generally be felt in the Douglas 
cul-de-sac, and should be evacuated immediately. Dr. 
Keith uses glass drainage-tubes in all cases where the accu- 
mulation of fluid is probable. The late Dr. Peaslee strongly 
recommended washing out the peritoneal cavity by injections 
frequently repeated. A weak solution of carbolic acid, liquor 
sodae chlorinatae, sulphurous acid, or potassium perman- 
ganate, at a temperature of 98° Fahrenheit, is used. In one 
case he continued the injections for seventy-eight days. He 
also gave two grains of quinine every four to six hours. To 
prevent the occurrence of septicaemia a carbolized linen tent 
may be inserted in the lower angle of the wound. 

If one can be procured, the patient should be placed on a 
water-bed after the operation. This can be filled with hot, 
lukewarm, cold, or ice-water, according to the exigencies of 
the case. At first it should be filled with hot water, and cov- 
ered with felt or flannel to retain the heat. If a rise of tem- 
perature occurs, the bed can be easily filled with ice-cold 
water, replaced as often as necessary. This way of reducing 
the temperature is preferable to a Kibbee's cot-bed, or Thorn- 
ton's ice-water cap. The latter may be used at the same time 
if needed. 



CHAPTER XIV. 

VAGINAL OVARIOTOMY— BATTEY'S OPERATION. 

VAGINAL OVARIOTOMY. 

An ovarian tumor can only be removed per vaginam in the 
early stages of its growth. The late Dr. W. L. Atlee re- 
moved a small tumor in this way in 1857, having previously 
tapped Douglas' cul-de-sac for a puriform collection. The 
first systematic operation was performed by Prof. Thomas in 
February, 1870. Since then, at least eight cases have been 
operated upon in this country, all terminating favorably. In 
Prof. Thomas' case the cyst was equal in size to a large 
orange, and could readily be pushed out of the pelvic cavity. 
It contained from six to eight ounces of a bile-like fluid, was 
without adhesions, and after being emptied, passed without 
difficulty into the vagina. It had a pedicle, which was trans- 
fixed by a needle armed with a double ligature, and tied on 
each side. The pedicle was returned into the abdominal cav- 
ity. One suture sufficed to close the vaginal wound. The 
operation lasted thirty-five minutes. It is worth recording 
that Prof. Thomas perfoi'med the operation eight times on the 
cadaver before trying it on a patient. 

A case of peculiar interest is reported by Dr. R. Davis, of 
Wilkesbarre, Pa.; the following is an abstract : ' 

Case XX. — On May 29, 1872, Dr. Davis was called to see 
Mrs. J. T., a multiparas, aged twenty-nine, and found her 

' Trans. Med. Soc. of Pennsylvania, 1874, 



142 DISEASES OF WOMEN. 

abdomen distended by two tumors of nearly equal size. One 
of them proved to be the womb adv^anced to about the sev- 
enth month of pregnancy ; the other an ovarian cyst extend- 
ing above the navel. On August 7th labor set in. Unsuc- 
cessful efforts having been made to lift the tumor out of the 
pelvis the cyst was tapped per vaginam. It collapsed, the 
womb descended, and a still-child, presenting by the breech, 
was born without difficulty. The woman made a rapid re- 
covery. Summoned again on September 15th to see his 
patient, Dr. Davis found the tumor had regained its original 
size and site. It was decided to attempt its removal per 
vagijiam. The operation was performed three days later. 
The patient was etherized and put in the lithotomy position. 
Two Sims specula were introduced into the vagina, and the 
posterior wall brought nicely into view. The vagina was 
caught with a tenaculum, drawn well down, and incised 
through the fornix to the extent of about four inches. After 
the hemorrhage had ceased, the peritoneum was divided 
upon a bent grooved director. The shining cyst-wall was thus 
exposed. Pretty firm pelvic adhesions were found to exist. 
The specula were removed, and, with the hand in the vagina 
these were broken up, the hand being carried to a point two 
inches above the umbilicus. 

The specula were re-inserted ; the cyst was secured and 
tapped. The long pedicle was secured by a double ligature, 
the stump was returned into the peritoneal cavity, and one 
end of each ligature was left uncut and brought out at the 
lower portion of the incision. Douglas' cul-de-sac was 
carefully sponged out, and two stitches in the upper portion 
of the incision completed the operation. She recovered with- 
out a bad symptom. For four days after the operation there 
was an abundant watery, dark-colored, and very fetid dis- 
charge /^r vaginam, sufficient to saturate completely three or 
four times a day a folded sheet placed under her. The tumor 
was composed of a single cyst of the right ovary, and 
weighed, with its contents, about nine pounds. 



VAGINAL OVARIOTOMY — BATTEY S OPERATION. 143 

BATTEY'S OPERATION, 

called spaying in the lower animals, consists in the extirpation 
of functionally active ovaries for the betterment of otherwise 
incurable diseases, and was first performed by Dr. Robert 
Battey, of Rome, Georgia, in 1872. Since then, over fifty 
cases have been reported by different operators. Dr. Battey 
advances the following propositions. The operation is jus- 
tifiable : 

1. In those cases of absence of the uterus in which life is 
endangered or the health destroyed by reason of the defi- 
ciency. 

2. In cases where the uterine cavity or vaginal canal has 
become obliterated, and cannot be restored by surgery, if 
grave symptoms be present. 

3. In cases of insanity or confirmed epilepsy, dependent 
upon uterine or ovarian disease, when other means of cure 
have failed. 

4. In cases of long-protracted physical and mental suffer- 
ing, dependent upon monthly nervous and vascular perturba- 
tions which have resisted persistently all other means of cure. 

To this list may be added, exhausting hemorrhages, depen- 
dent on sub-peritoneal or interstitial fibroid tumors. Dr. 
Goodell operated on a maiden lady, thirty-three years of age, 
in October, 1877, for painful menorrhagia caused by a fibroid 
tumor in the uterus. He removed both ovaries /^r vagiiiain. 
When seen in January, 1878, she had had no return of men- 
struation, the tumor had lessened in size more than one-half, 
all suffering had disappeared, and from being bedridden, she 
is now able to walk two miles at a stretch. Professor Hegar, 
Germany, has twice successfully removed both ovaries for 
severe hemorrhage caused by intramural fibroids, resulting in 
cure. 

Operation. — Dr. Battey says : " My method of operating 
is briefly this : I place the subject upon the left side, semi- 
prone ; open the vagina and retract the perineum with a 



144 DISEASES OF WOMEN. 

Sims speculum having a broad, rather short blade which is 
but slightly cupped. The cervix is seized with stout volsella, 
the uterus drawn down under the pubic arch, and the vaginal 
membrane and cellular tissue incised with scissors, say one 
and a half inch in the median line of the posterior cul-de-sac, 
beginning immediately behind the uterus. If there is bleed- 
ing, which there usually is not, it is controlled by a jet. of ice- 
water, or by torsion, after which the peritoneum is incised. 

** I now direct an assistant, with a hand upon the hypogas- 
trium, to press the abdominal organs downward into the pel- 
vis whilst I pass a finger up into Douglas' fossa, and, assisted 
by suitable forceps, bring down the ovary into the vagina 
and throw a ligature about its base. The other ovary having 
been similarly treated, the organs are removed in turn by 
the ecraseur, allowing time sufficient in the crushing to give 
immunity from hemorrhage. The vagina is now syringed 
out and the patient put to bed. No ligatures or sutures 
should be left in the tissues ; these I regard as both superflu- 
ous and detrimental." 

In certain cases, complicated by adhesions, it is preferable 
to remove the ovaries through an abdominal incision. Both 
organs should always be removed. 



CHAPTER XV. 
PUERPERAL DISEASES. 

PUERPERAL FEVER. 

This disease generally occurs within two or three days 
after confinement. The more marked symptoms are rapid 
pulse, hurried breathing, high temperature, and abdominal 
pain. The attack is sometimes preceded by a chill, followed 
by intense headache, tympanites, loss of appetite, vomiting, 
and delirium. The lochial discharge is often suppressed, 
although it is sometimes profuse and very offensive. The 
mammary secretion is arrested. At the commencement of 
the attack the patient's face is flushed and her skin hot. 
Diarrhoea is more common than constipation. The urine is 
turbid, voided often and painfully. Childbed fever, as it is 
sometimes called, essentially consists in a species of blood- 
poisoning, accompanied in many cases by peritonitis, com- 
mencing at the womb and spreading all over the abdomen. 

Puerperal fever sometimes prevails as an epidemic in lying- 
in hospitals ; but it also occurs epidemically in private prac- 
tice in some particular locality, or follows the track of a sin- 
gle practitioner. The burden of evidence goes to prove that 
at least one form of the disease is contagious. A physician 
attending a case of erysipelas, scarlatina, or any similar dis- 
ease, should not attend midwifery cases without an entire 
change of clothes, and repeated ablutions. Before making 
an examination he shoijld wash his hands in a solution of 
potassium permanganate, and industriously ply the nail-brush. 

Many thousands of pages have been written about the 
lO 



146 DISEASES OF WOMEN. 

nature of puerperal fever. Its very existence has been called 
in question by high modern authorities. In this country Dr. 
Fordyce Barker is the principal advocate of its special entity. 
He asserts that the symptoms " are essential, and are not the 
consequence of any local lesion, and it is as much a distinct 
disease as typhoid fever.'' Dr. Schroeder, on the other hand, 
says that ** puerperal fever is nothing else but poisoning with 
septic matter from the genital organs." It is well to bear in 
mind that there are at least two forms — sthenic and asthenic ; 
and that the treatment which is needed in the former may be 
positively injurious in the latter form. 

TreaUnent. — It is of the greatest importance to see the 
patient early, that is, within two hours of the attack. In a 
robust woman, bleed from the arm to faintness, and envelop 
the entire abdomen in a hot poultice covered with oiled silk. 
After four hours have elapsed, bleeding is of doubtful utility. 
Give opium in doses sufficient to quiet the peristaltic action 
of the bowels, and tinct. veratrum viride in four-drop doses 
every hour till the rapidity of the pulse is moderated. If the 
opium is vomited, inject a saturated solution of morphia with 
a hypodermic syringe. If the vaginal discharges are fetid, 
throw up hot injections of Condy's fluid. 

After the first day, give quinine in ten-grain doses night 
and morning, or oftener. Use a bedpan, and draw ofl" the 
urine with a flexible catheter once in four hours, so as to se- 
cure absolute rest as far as possible. 

If the patient has already lost much blood, or is constitu- 
tionally anaemic, do not bleed, but depend on rest, opiates, 
poultices, and simple nourishment (of which the best form is 
good milk). During the first day or two of the disease we 
should attend the patient assiduously, becoming, as Dr. Gooch 
says, " not only her physician, but her nurse." ^ 

Case XXI. — Mrs. R., a primipara, was safely delivered of 

^ For an exhaustive account of this subject, the student is referred to Essays on 
the Puerperal Fever, issued by the Sydenham Society. London, 1849. 



PUERPERAL CONVULSIONS. 147 

a boy, May 2, 1869, at noon. She was a young, healthy 
woman, and the labor was natural in every respect, lasting 
about seven hours after the discharge of the liquor amnii. 
Two days later she was suddenly seized with a chill, followed 
by fever, peritonitis, and tympanitis. The surroundings w^ere 
not quite up to the mark ; but she received as good care as 
the majority of women in straitened circumstances. 

The treatment mainly consisted in the free administration of 
powdered opium (conjoined with small doses of calomel dur- 
ing the first day), poultices to the abdomen for thirty hours, 
and warm water vaginal injections (90°). The late Dr. Wm. 
F. Stevens saw her in consultation, May 5th. The disease 
steadily progressed, and she died May 7th. The lochial dis- 
charge was arrested, and no milk made its appearance in the 
breasts. This is the only case of puerperal fever which has 
occurred in my own practice for sixteen years. No autopsy 
was allowed. 

PUERPERAL CONVULSIONS 

may occur before, during, or after delivery. The symptoms 
once seen, can hardly fail to be afterward recognized. During 
the attack the patient has both tonic and clonic spasms, often 
bites her tongue, ejects froth and blood from her mouth spas- 
modically, and labors under difficulty of breathing, it may be 
to the extent of stertor. In severe cases the color of the face 
is dark brown, like mahogany. 

Generally, the urine contains an appreciable quantity of 
albumen or paralbumen.- The attack sometimes comes on 
suddenly, almost without any warning. In other cases, how- 
ever, the attack is preceded by intermittent headache, which 
latterly becomes persistent ; dimness of vision, which may 
culminate in total blindness ; oedema of the face and ankles, 
and difficulty in articulation. Besides these premonitory 
symptoms, there may be ringing in the ears, sparks before 
the eyes, and irritability of disposition. 

Death may occur from asphyxia during the paroxysm ; or 



148 DISEASES OF WOMEN. 

the patient may become comatose, and finally die from 
exhaustion. Primiparae are more subject to convulsions than 
multiparse, and the mothers of illegitimate children than 
married women in comfortable circumstances. The etiology 
of the disease is still somewhat obscure. Albuminuria is not 
always present before convulsions, and it is often present 
when none occur. It is now generally admitted that excess 
of urea in the blood acts as an irritant poison, and very often 
is the immediate cause of the convulsions. But cases occur, 
dependent on emotional causes, in which there is no reason to 
believe that the kidneys are at fault. Before labor, convul- 
sions may be excited in nervous women by quite a variety of 
causes, such as constipation, distended bladder, indigestion, 
or a sudden fright. During labor, pressure of the child's 
head on a rigid cervix, or the prolonged severity of the labor- 
pains may bring on convulsions. After a delivery which has 
been attended with great loss of blood, the sudden change in 
the circulation, and deficiency of nervous stimulus, may ac- 
count for their occurrence. Twin pregnancies, especially in 
primiparae, are more apt to be complicated with eclampsia. 

Treatment. ■ — If the attack occurs before labor, and the 
patient is robust, bleed from the arm to the extent of twelve 
or sixteen ounces. This itself will often arrest convulsions. 
It is generally safe to administer an active cathartic. . A 
teaspoonful of sulphur with one-fourth of a grain powdered 
elaterium, in molasses, almost always produces a copious 
evacuation. If not, it should be repeated in half an hour. 
Ascertain what the patient has eaten during the day, and if 
there is any reason to suspect the presence of undigested food 
in the stomach, give a prompt emetic (zinc sulphate, grs. xvj.), 
followed by copious draughts of tepid water and irritation of 
the fauces until emesis results. It is well, also, to use the 
catheter. 

Chloroform is an excellent remedy, given by inhalation. 
We should bear in mind, however, that it is a powerful anaes- 
thetic, at least four times as potent as sulphuric ether, and 



PUERPERAL CONVULSIONS. I49 

administer it cautiously. See that the room is well ventilated, 
that the chloroform vapor is sufficiently diluted with atmos- 
pheric air, and that the patient lies on her side while 
inhaling it. Both chloroform and sulphuric ether act as diu- 
retics. Hydrate chloral, per rectum, may be substituted for 
the chloroform. It should be dissolved in a good deal of 
water. 

If the convulsions recur, it may be advisable to induce 
labor by passing a flexible bougie to the fundus, by rupturing 
the membranes, by placing a sponge-tent in the cervix, or even 
by manual dilatation of the os uteri. Should convulsions com- 
mence during labor, deliver as speedily as possible, using the 
forceps, or turning, as the case may require. Chloroform may 
be cautiously inhaled during delivery. If convulsions occur 
after delivery, the best remedy is morphia by hypodermic 
injection in small repeated doses, with iced hydrocyanic acid 
by the mouth (gtt. iv. every half-hour). If the urine is 
scanty, infusion of digitalis may be used in small doses often 
repeated, or the moistened leaves may be applied as a poul- 
tice over the lumbar region. 

In all cases of gestation where we have reason to dread the 
occurrence of convulsions, we should try to remove the renal 
congestion by means of mild diuretics and diaphoretics. See 
that the bowels are kept in a soluble state by saline laxatives 
(sodium phosphate) ; and, if she is anaemic, improve the tone 
of the general health by giving gentian, quinine, iron, or 
potassium chlorate. The greatest attention should be paid 
to cleanliness of skin, pure air, nourishing, easily digested 
food, and mental hygiene. Dr. Noeggerath strongly recom- 
mends skimmed milk as having a radical influence on albu- 
minuria. He, also uses chloral hydrate to allay the convul- 
sions. Jaborandi produces diaphoresis more certainly than 
any other drug; but it' should not be given to patients with 
a feeble heart, as the depression which follows its use is often 
considerable. Dr. Bowstead, of High Wycombe, relies on 
subcutaneous injections of morphia and aconite. 



ISO DISEASES OF WOMEN. 

PUERPERAL INSANITY. 

This is not a common disease. It most frequently occurs 
in women predisposed to mental derangement, especially in 
those whose mind is depressed, as in the mothers of illegiti- 
mate children. It is generally associated with debility, and 
is rarely complicated with phrenitis. There are four forms of 
the disease : 

1. Temporary furor, or delirium, mainly caused by the se- 
verity of the pains. 

2. Insanity, dependent on hereditary taint, excited by the 
changes incident to pregnancy or labor. 

3. True puerperal mania, following soon after confinement, 
not hereditary, but the result of hemorrhage or mental dis- 
tress. 

4. Melancholia, occurring later, often during lactation, ac- 
companied by anaemia and much debility. 

There is nothing specific about the disease as it is mani- 
fested in puerperal women in any of its forms. It rarely ends 
in death. The first form only lasts a short time — a few hours 
or days at most, and is dependent on cerebral hypersemia. 
The second form constitutes about fifty per cent, of all the 
cases of puerperal insanity. This includes those which arise 
during pregnancy, although^ strictly speaking, these are not 
puerperal. And, in this variety, so much depends on the 
peculiarities of each individual case, it is more difficult to 
arrive at a correct prognosis. The third form results from 
loss of blood, unusually severe after-pains, sudden fright, or 
mental depression, and is more amenable to treatment. The 
fourth form is in many respects the worst of all, being char- 
acterized by attempts at suicide. It is apt to persist longer 
than the others. 

Treatment, — Proper restraint, watchful supervision by a 
trained nurse accustomed to the care of such patients, nutri- 
tious food, fresh air, gentle exercise, light work, bromide of 
sodium Avhen needed, avoidance of mental excitement, and 



MASTITIS. 151 

special attention to the predisposing causes in each case, 
comprise the main features of the treatment. It is rarely ne- 
cessary to send the patient to an asylum. 



MASTITIS, 

or inflammation of the mammary gland, may be situated 
chiefly in the gland itself (parenchymatous inflammation), or 
in the connective areolar tissue. In some rare cases, the 
inflammation commences underneath the gland, between it 
and the pectoralis major muscle. Mastitis may be caused by 
obstruction of the lacteal ducts, exposure to cold, a blow, or 
by blood deterioration. Erysipelas sometimes attacks the 
skin over the breast, marked by a deep red or purplish hue, 
and attended with a pungent, burning pain. When the paren- 
chyma is mainly aflected, suppuration soon takes place. 

Treatment. — When the gland is engorged with milk, a little 
may be drawn off" by means of a hot- water bottle. Select a 

ip^fj^^^r?^!^? ^.^^■,^^^t^■lJ^l,..u^^=^■^ ! ^:- | J^l! ^ l l ^^ l lll4y^^J^ p; 



Fig. 37. — Abscess Lancet. 

pint bottle with a smooth mouth ; fill it with hot water 
(nearly boiling), pour out the water, and apply the empty 
bottle firmly to the base of the nipple. Milk will flow into 
the bottle as it cools, a partial vacuum being formed. Of 
course, care must be taken not to burn the patient. Only a 
small quantity of milk is got in this way ; but it is better to 
repeat the process than to use a breast-pump. 

If erysipelas sets in, paint the skin with tincture of iodine, 
and apply dry heat by means of hot bran in a flannel bag. If 
the skin and subjacent tissue are tense, cedematous, smooth, 
and glistening, make free superficial incisions in lines radiat- 
ing from the nipple, avoiding the areola if possible. In all 



152 DISEASES OF WOMEN. 

cases, the breast should be efficiently supported ; and the 
best way to do so is to apply long, narrow strips of freshly 
prepared adhesive plaster, shingle fashion, to the lower half 
of the breast, stitching a bandage to the combined ends at 
each side, and tying them round her neck. 

If pus has formed, make a free deep incision with Syme's 
abscess-lancet, in such a direction as will do the least injury 
to the lacteal ducts. If matter forms underneath the gland, 
pass an exploring-needle in that direction, and, if pus is found, 
open with a narrow tenotomy-knife. 

Where mastitis depends on constitutional causes, special 
attention must be directed to improving the patient's general 
condition by tonics, mild stimulants, easily digested food, and 
change of air. 

MASTODYNIA. 

This affection may be defined as pain in one or both 
breasts, not arising from inflammation. Many nervous, sus- 
ceptible women experience such a pain at every menstrual 
period ; it is also apt to occur soon after conception, and the 
trouble may po'ssibly continue for months or years. The left 
breast is more frequently affected. The amount of pain varies 
considerably in different individuals, and, like other neuralgic 
affections, it is apt to radiate to parts adjoining. Weakly, 
dyspeptic, sterile women are most subject to it. 

Treatment.-— Y\i^ first indication is to relieve the pain, at 
least temporarily, by local remedies, among which the best 
are dry heat (bag of hot bran or salt) and cloths wet with 
warm laudanum. Small doses tincture gelseminum (four 
drops), repeated every hour until the constitutional effects be- 
gin to appear (vertigo and muscular debility), sometimes work 
admirably. 

Particular attention should be paid to the state of the 
womb, ovaries, and general health. If the cervix uteri is in- 
flamed, abraded, or everted, or if the entire organ is displaced, 
appropriate treatment must be given. Occasionally the ova- 



CHAPPED NIPPLES. I 53 

ries are mainly at fault, requiring leeches or blisters. If the 
liver is sluggish, give two or three hepatic pills, followed by 
aloes and belladonna laxative. After the bowels have been 
freely evacuated, one of the very best remedies is arsenic in 
small doses after meals. Iron may be needed, but not while 
the patient remains constipated. 



CHAPPED NIPPLES, 

though insignificant in appearance, give rise to more ma- 
ternal suffering than some formidable-looking diseases. The 
vascular little organ is covered with a thin, delicate cuticle, 
easily abraded, especially at the apex and base, where it 
forms folds. In some women the nipples are flat, and project 
so slightly above the surface that the infant fails to get a suf- 
ficient hold for suction. In such cases steps should be taken 
before delivery to stimulate their growth by gentle friction, 
applying the primary current of electricity, drawing out the 
nipple by means of the hot-water bottle already described, 
and wearing a wire shield, lined with absorbent cotton, to 
prevent pressure by the dress. It is also advisable, during 
the latter months of gestation, to toughen the epidermis by 
exposure of the nipple to the air as much as possible. Exco- 
riations may be avoided by directing the mother to always 
dry the nipple thoroughly after nursing. 

Treatmejit. — When the surface is simply excoriated, rest 
for a day or two, and painting the raw surface with a plasma 
of plumbum iodide will effect a cure. If there is a fissure or 
chap, cauterize with solid argentum nitrate. Take a clean 
silver probe, heat it in the flame of a spirit-lamp, and roll it 
in powdered crystals of the nitrate. This will give a suffi- 
cient coating of the caustic, which should be carefully ap- 
plied to the bottom of the fissure. A few fibres of absorbent 
cotton, soaked in a saturated solution of tannin, may be left 
in the fissure, if very deep. 



154 DISEASES OF WOMEN. 



AGALACTIA. 



Non-secretion of milk can only be reckoned a disease in 
women who have conceived and carried the child to a viable 
age. Agalactia is the normal state in virgins, sterile women, 
old women, and men ; and the presence of milk in the breasts 
of either would be abnormal, although several such cases in 
all four classes have been chronicled by reliable observers, in 
which abundance of milk was secreted for a considerable pe- 
riod of time. 

Non-secretion of milk soon after delivery may depend, first, 
on deficient development of the mammary glands ; second, 
on deterioration of the blood ; third, on a blow or other in- 
jury, followed by inflammation ; fourth, on the attack of some 
acute disease, such as puerperal fever. When the gland is 
rudimentary, and has undergone no change during gestation, 
the disease may be safely pronounced incurable. If a woman 
conceive during lactation, owing to the sympathy which exists 
between the uterus and mammae, there is often complete sup- 
pression of the milk-fiow, or a great reduction in quantity. 
Agalactia produced by acute disease is only temporary if the 
patient recovers. 

Treatment. — If the glands are evidently undeveloped, with 
flat, non-erectile nipples, treatment is almost hopeless. A 
mild constant current of electricity from a galvanic battery 
might be used for half an hour at a time, several times a day ; 
the nipples drawn out with a hot-water bottle ; and the 
child applied occasionally for a few days. 

Where agalactia, partial or complete, depends on constitu- 
tional debility, the obvious course will be to build up the 
system by suitable food, fresh air, massage, and tonics. A 
poultice of castor-oil plant leaves boiled in a small quantity 
of water till quite soft, is a favorite old-fashioned remedy ; an 
opening should be left for the nipple ; and the poultice re- 
peated every four hours. It is also well, in all cases, to feed 
the patient with soups, milk, eggs, oyster broth, chocolate, 



GALACTORRHCEA. 155 

and gruels. A small quantity of beer or wine is sometimes 
beneficial. 

GALACTORRHOEA. 

There are two well-marked forms of this disease : one in 
which the milk, though secreted in unusual quantity, still re- 
tains its due proportions of cream and casein ; in the other 
the excess is chiefly water. The term galactorrhoea also ap- 
plies to persistent continuance of the secretion after the child 
has been weaned. In most cases the effects are debilitating, 
more especially when the milk is watery. Among the well- 
to-do classes, a frequent cause of galactorrhoea is overfeeding 
and the free use of fermented liquors. It is very seldom that 
a healthy young woman needs ale or porter while nursing. 
Another cause is the habit of suckling a child for eighteen 
months or two years, under the idea that it prevents concep- 
tion. The watery form may arise from indigestion, or from 
some kind of uterine disease. In such cases the blood is 
generally deteriorated. 

Treatment. — Where the milk is rich and too abundant, a 
judicious restriction of diet and the administration of saline 
laxatives will generally set matters right. The copious 
watery secretion (which has been called mammary diabetes) 
is more difficult to cure. Iron tonics are sometimes of ser- 
v^ice ; iodide of potassium in four-grain doses four times a 
day has been much extolled ; but the drug on which most re- 
liance can be placed is belladonna, used both externally and 
internally. The ice-poultice is also a good local remedy, 
steadily applied for hours continuously. It is made in this 
way : spread dry Indian meal about an inch thick on the 
centre of a large pocket-handkerchief; cover the meal with 
small pieces of ice in rows ; fold the cloth on all four sides, 
fastening with stitches so as to make a flat bag, and lay 
the meal side next the s4cin over the breast. The ice as it 
melts is absorbed by the meal, and the sensation of a soft 
surface is more agreeable to the patient. 



156 DISEASES OF WOMEN. 

A *' dry diet" should be prescribed ; that is, one in which 
the amount of fluids taken is restricted to the smallest possi- 
ble quantity. 

PHLEGMASIA DOLENS, 

or milk-leg, generally occurs in multiparas of a feeble consti- 
tution, from the fourth to the twentieth day after confinement, 
appearing in the left leg more frequently than in the right,' 
and in some cases attacking the other leg before it has run 
its course in the one originally affected. The disease often 
commences with a feeling of weight in the pelvic region, fol- 
lowed by a rigor. Sometimes the first symptom is a sudden 
pain in the calf of the leg. But the most prominent symp- 
tom is swelling, with slight irregularities, commencing at the 
upper part of the thigh, and extending downward until the 
whole limb is involved, presenting a characteristic white, 
glazed appearance, whence the popular name " milk-leg." 
The principal veins can readily be felt as hard cords, and the 
larger lymphatics are inflamed and swollen. The inguinal 
glands are also enlarged and tender. The lochial discharge 
and the lacteal secretion are partially or totally arrested. 
The pulse is increased in frequency, and the temperature of 
the affected limb rises. While the disease is at its height the 
limb does not readily pit on pressure, and the patient is 
powerless to move it. After eight or ten days the more 
prominent symptoms subside, leaving the limb still swollen 
and feeble, and the patient much debilitated. The labium of 
the affected side is also swollen, and, when only one leg is 
attacked, the swelling is confined to the labium pudendi of 
that side. 

The pathology of phlegmasia dolens is still somewhat ob- 
scure. It is scarcely necessary to say that the old idea of 

^ In many diseases of women the left side is attacked more frequently than the 
right ; for example, the inframammary pain on the left side, and neuralgia of the 
left ovary. The same remark applies to some diseases of men. 



PHLEGMASIA DOLENS. 157 

lacteal metastasis is quite unfounded. The more modern 
theory that it depends on phlebitis is not much better. 
Thrombosis undoubtedly occurs in most cases; but it is more 
an effect than the cause of the disease. The fact that it oc- 
casionally occurs during gestation, also after abortion, after 
surgical operations in the pelvic cavity, during the progress 
of cancer uteri, and even in males, demonstrates that it is 
more a constitutional than a local disease. It seems to de- 
pend on a peculiar state of the blood, with a tendency to 
coagulation. In many cases, inflammation of the vessels and 
cellular tissue exists as a complication, but it cannot be set 
down as a primary cause. Generally the disease proves tedi- 
ous, several weeks or even months elapsing before the limb 
recovers its tone. 

TreaUnent. — Elevate the leg on a suitable inclined plane ; 
or the lower part of the mattress may be raised. This re- 
lieves the oedema. Give opiates in frequently repeated small 
doses to allay the pain and restlessness. Acetate opii (gtt. vi.) 
with tincture aconite (gtt. ij.) every hour, meets this indication. 
While the swelling remains tense, gently rub upward with a 
piece of soft flannel saturated with equal parts acetate opii 
and infusion belladonna. Envelop the entire limb in fine 
cotton wadding, and cover with oiled silk or sheet gutta- 
percha. Arrange the dressings so as to disturb the parts as 
little as possible. 

When the acute stage has passed, the best treatment is to 
swathe the hmb with a Martin's rubber bandage, which at 
first maybe kept on continuously, but after awhile need only 
be worn during the day-time. Sometimes small blisters are 
needed to promote absorption. Tonics, sea-bathing, gener- 
ous diet, and change of air, are all of service, if the patient can 
get them. 

SUBINVOLUTION. 

At the end of gestation the uterus weighs about two 
pounds. Six weeks after delivery it should weigh from two 



158 DISEASES OF WOMEN. 

to three ounces. The fundus uteri, immediately after labor, 
may be felt a little below the umbilicus. On the eighth day 
after delivery it can barely be felt above the pubis, and eight 
days later it has sunk below the level of the superior strait. If, 
therefore, after the lapse of sixteen days, the womb still re- 
mains above the pubis, we are warranted in concluding that 
there is arrest of involution. 

Subinvolution is a species of hypertrophy, and may depend 
on one of two causes, namely, deficient contractility or defi- 
cient absorption. After childbirth, tonic contraction not only 
drives out a large quantity of blood from the womb, but per- 
manently closes many vessels. The muscular fibres, in great 
part, undergo fatty degeneration and are absorbed. Both 
processes depend for their activity on the state of the general 
health. A robust young woman possesses both the muscu- 
lar and the glandular power to effect involution rapidly ; a 
weak, nervous woman does not ; consequently the womb re- 
mains larger than it ought to be. 

The more immediate causes of subinvolution are : repeated 
abortions ; too early getting up from childbed or miscar- 
riage ; shirking lactation ; and general debility. A state of 
hypertrophy analogous to subinvolution may be induced by 
the presence of uterine tumors, pelvic peritonitis or cellulitis, 
metritis, retroversion, prolapsus, or by any agency which im- 
movably fixes the uterus. 

The symptoms which direct attention to this state of 
things are, a dragging sensation and sense of weight in the 
pelvis, backache, dysuria, and difficulty in walking. On 
making a bimanual examination the w^omb will be found 
enlarged ; it may even be felt above the pubis. The passage 
of a uterine sound will show a depth of three inches or more, 
and in many cases the organ will be found retroverted or pro- 
lapsed. 

Treatmeiit. — Special attention must be directed to the 
cause. If subinvolution is met with soon after delivery at 
term, local measures calculated to promote contraction and 



SUBINVOLUTION. 1 59 

absorption, along with constitutional remedies of the same 
kind, are indicated. Scarify the congested cervix freely. 
Employ the hot-water douche night and morning. Insert a 
cotton pessary saturated with lead iodide and glycerine, and 
instruct the patient how to do it herself, two being used daily. 
Order rest in the horizontal posture, with the lower limbs 
and pelvis somewhat elevated. Give potassium iodide or 
potassium bromide in eight-grain doses twice a day. If the 
circulation is feeble, add digitalis in small doses. 

If the subinvolution results from bearing children in too 
rapid succession, counsel sexual abstinence. If dependent 
on overlactation and general w^eakness, get her to wean the 
child, and advise change of air, with plain, nourishing diet. 
When contingent on repeated abortions, or any agency 
which fastens the womb in one position, very small blisters 
frequently repeated, by applying acetic cantharidal collodion, 
will promote absorption. If not contraindicated by inflam- 
mation, a Smith's closed lever-pessary will help to stretch 
adhesions. We may be certain that hypertrophy will con- 
tinue so long as the uterus is immovable. It is scarcely 
necessary to add that the general health should be carefully 
attended to and improved by the various common sense 
methods so frequently alluded to already. 



CHAPTER XVL 

PUERPERAL Dl^EK'^ES— {Continued.) 

ABORTION, 

or miscarriage, may be defined as a separation and expulsion 
of the foetus before the time that it is viable. After the 
seventh month the process would be called premature birth. 
Abortion is more common in women Avho have previously- 
borne children ; and, having once taken place, it is likely to 
occur in subsequent pregnancies about the same period of 
gestation. Miscarriage is attended with greater risk to the 
mother between the third and sixth months than at an earlier 
or later period. 

Leaving out artificially induced abortion, the causes which 
bring it on are very numerous. Dr. Braxton Hicks, of Lon- 
don, says that the habit of the uterus, in ordinary pregnan- 
cies, is to contract at intervals of from five to twenty minutes, 
and these contractions are observable as early as the third 
month of pregnancy. Any sickness which partially arrests 
excretion from the liver, the lungs, the kidneys, or the skin, 
has a tendency to produce abortion ; for it is well known that 
hypercarbonized blood acts as an exciter of muscular action, 
especially on the uterus. These normal contractions are 
intensified, and a miscarriage follows. Retroflexion, prolap- 
sus, anaemia, and disease of the chorion, act as predisposing 
causes. In some women, anything which produces active 
congestion of the genital organs, such as frequent coitus, 
dancing, intoxicating liquors, and mental excitement, also 
act in the same way. A sudden chill, an exhausting diar- 



ABORTION. l6l 

rhoea, a blow on the abdomen, or a mental shock, may be 
the proximate cause. Nervous and plethoric women are 
more liable to miscarry than others. The death of the foetus 
necessarily results in abortion. * One of the most frequent 
causes of fetal death is disease of the placenta. Syphilis is a - 
too common cause. 

The symptoms first noticed are a sense of weight in the 
pelvic region, chills, nausea, and hemorrhage. When abor- 
tion occurs during the first or second month, it is difficult of 
detection, the bleeding being set down as a return of men- 
struation, and the minute foetus escaping observation in a 
blood-clot. At that early period, too, the expulsive pains 
are not as characteristic. The presence of a foetus or placenta 
of course settles the diagnosis. 

Treatment. — If seen at a sufficiently early period, our 
efforts should b^ strenuously directed to prevent abortion, 
for sometimes we succeed beyond our expectations. In one 
(personal) case the membranes projected an inch beyond the 
OS uteri, and abortion appeared to be inevitable, but, at the 
next visit, a few hours later, the ovum had retreated, and she 
went to the full period without further trouble. 

Send the patient to bed, on a hard mattress, in the dorsal 
position, with the pelvis and legs somewhat elevated. Keep 
the room cool. Stimulating articles of diet must be avoided 
as much as possible. Medicine, in such cases, is generally 
of doubtful utility. If restless from pain, a two-grain opium 
suppository may be placed in the rectum, or a hypodermic 
injection of morphia administered. Small doses of infusion 
digitalis are sometimes advisable. 

If hemorrhage persists, insert a glass speculum, and plug 
the vagina with small rolls of iodized wool smeared with vase- 
line. The anterior cul-de-sac and Douglas' pouch should be 
firmly packed with these pieces, but it is seldom necessary to 
fill the whole vagina. They should be removed within twelve 
hours, by inserting the lower blade of a Neugebauer's specu- 
lum, and withdrawing piece after piece with dressing forceps. 
II 



l62 DISEASES OF WOMEN. 

Perfect rest is essential to success ; she must lie on her back 
for several days, even after the bleeding has stopped ; and, in 
severe cases, it would be well to draw off the urine once in 
four hours with a flexible catheter. 

In all cases of habitual abortion, total abstinence from sexual 
intercourse after conception should be ordered. Sir James 
Simpson had great faith in large doses of potassium chlorate 
(gr. XV., 3 t. d.). When dependent on a syphihtic taint in 
either parent, a mercurial course, followed by potassium 
iodide for a long period, furnishes the only chance for bearing 
healthy offspring. 

In a great many cases, however, we are not called in until the 
process has advanced so far that abortion is inevitable. Dur- 
ing the first and second months the entire ovum, including the 
secundines, generally pc^sses into the vagina ; and rest for a 
couple of weeks, with due attention to cleanliness, comprise 
the treatment. In the third month, or later, the placenta is 
apt to be retained after the foetus has been expelled. If 
called before this takes place, special pains should be taken 
to insure the extrusion of the whole mass, and this can ordi- 
narily be effected by plugging the vagina, which excites the 
womb to contract. If the placenta should unfortunately be 
retained, a modification of Crede's method may be tried. 
Press the posterior wall firmly with one hand externally, 
while two fingers of the other hand in the vagina make pres- 
sure on the anterior wall. If this manoeuvre fails, press the 
fundus down with one hand outside, and insert one or two 
fingers into the cervix, higher than the fetal mass, so as to 
hook it downward. Forceps are seldom or never serviceable. 
The patient should previously be etherized. She should be 
attended to at least as assiduously as after labor at term. 
She ought to occupy the recumbent posture as long, have 
her diet regulated, be guarded carefully from excitement, 
and have the vagina washed out daily to prevent septicaemia. 

There can be no doubt that criminal abortion prevails to 
an alarming extent in this country. Specialists and especial- 



EXTRA-UTERINE GESTATION. 163 

ists should be on their guard against being made the dupes 
of designing women who request an examination with a view 
to abortion as a result. While it is true that the uterine 
sound has in some cases been passed to the fundus uteri, 
during gestation, without injury, there is always risk in so 
doing, and the sound should never be used where pregnancy 
is even suspected. 

EXTRA-UTERINE GESTATION 

consists in the development of the ovum outside the womb. 
Authors specify eight or ten varieties, but they may be ad- 
vantageously reduced to three, one of which is somewhat 
doubtful. These are : Tubal pregnancy, in which the foetus 
is developed in some part of the Fallopian tube ; abdominal 
pregnancy, where the foetus lies in the abdominal cavity ; 
and ovarian pregnancy in which the ovum remains in the 
Graafian vesicle, receiving the male element there, and being 
developed in the ovary. This last variety, if it ever occurs, 
is certainly rare. 

Tubal Pregnancy. — This may happen in any portion of the 
oviduct ; at the fimbriated extremity, near the uterine end, 
or in the middle of the tube. Instead of passing on to the 
uterus, the fecundated ovum is arrested in the tube, and 
commences its development there. Substantially the same 
coverings envelop the foetus as when normally located in 
the uterus, the muscular layer, however, being very thin. 
Within three or four months the sac ruptures, concealed 
hemorrhage occurs, followed by shock, and the patient almost 
invariably dies. 

Abdominal Pregnancy. — In this variety the impregnated 
ovum, from some unexplained cause, fails to enter the ovi- 
duct, and falls into the abdominal cavity, where it finds a 
peritoneal nest. In all eases of extra-uterine gestation, the 
foetus is enveloped in a true chorion and amnion, without 
which it could not be developed. In abdominal pregnancy, 
the irritation set up by its presence results in the formation 



l64 DISEASES OF WOMEN. 

of a sac resembling connective tissue, very vascular, and 
capable of growth pari passti with the foetus. This sac sel- 
dom ruptures until after the ordinary period of intra-uterine 
life has been passed. The foetus grows apace, and manifests 
its life by motions more obvious than usual, on account of the 
absence of uterine walls. If not removed at term by ad- 
dominal section, it soon dies and undergoes certain changes. 
The soft tissues become decomposed, suppuration takes 
place, and a communication is formed between the sac and 
intestine, or other hollow organ, or the abdominal wall is 
perforated. In this way, if the patient survives long enough, 
the whole foetus may finally be discharged, and the patient 
recover. More frequently she dies of peritonitis, hectic fever, 
or exhaustion. In rare cases, the liquor amnii is absorbed, 
the foetus is moulded by pressure into a pultaceous mass, 
which finally shrinks into a tumor of almost stony hardness, 
Avhich may remain encysted for many years. When this oc- 
curs the foetus is called a lithopsedion. 

Ovarian Pregnancy, especially that which forms near the 
surface of the ovary, resembles abdominal pregnancy in all 
essential particulars. 

The principal symptom of extra-uterine gestation is severe 
pain, limited to a particular spot in the lower part of the ab- 
domen. The subjects of tubal pregnancy seldom apply for 
advice before the tube ruptures and signs of internal hem- 
orrhage, with sudden and alarming prostration, set in. In 
abdominal pregnancy, the sac is very movable, and feels like 
an ovarian cyst at an early stage, for which it has been some- 
times mistaken. Pain is not often present in this form. To 
attain a correct diagnosis much will depend on the thinness 
of the abdominal walls, through which the fetal parts may be 
felt, while the uterus is not much enlarged and empty. 

Treatment. — If detected before rupture, the best plan is to 
puncture the sac with an aspirator needle, and inject an aque- 
ous solution of opium. The foetus then dies, and is disposed 
of either by inflammation and absorption, with subsequent 



EXTRA-UTERINE GESTATION. 165 

perforation, or by conversion into a lithopaedion. Fetal 
growth may also be arrested by passing a strong current of 
electricity through the sac, as in electrolysis.' More com- 
monly the sac has ruptured before we see the patient, and 
the only course which affords a chance of success is to make 
a careful incision — vaginal or abdominal — remove the foetus, 
and arrest the hemorrhage. Paquelin's thermo-cautery may 
be used to sever the cord and stop bleeding points. Each 
case must be decided on its own merits. One point only 
all late experience has made evident. If the placenta lies 
outside the sac, or is at all adherent, it is better to leave it 
alone, and trust to its expulsion naturally. A moderately 
large glass drainage-tube should be left in the lower angle of 
the wound, and the cavity kept sweet by frequent washings 
with a weak solution of iodine. 

Where the pregnancy is abdominal and the foetus has ar- 
rived at or near term, after a thorough bimanual examination 
under ether, with the left hand in the vagina, while an assist- 
ant passes the uterine sound, the Caesarean section should be 
performed. With modern antiseptic precautions, the risk to 
the mother is not much greater than to leave matters alone, 
and it certainly affords the child a much better chance for 
life. The placenta must not be removed ; simply the cord 
tied and cut as if it were a pedicle, and a drainage-tube left 
in. 

If the foetus is dead (evidenced by arrest of fetal move- 
ments and stoppage of the fetal heart), and no urgent symp- 
toms supervene, it is best to follow an expectant treatment. 
The occurrence of septicaemia would necessitate active meas- 
ures to remove the sac and its contents. Where a gradual 
discharge by the rectum or other fistulous opening occurs, 
the patient's strength must be kept up by good food, stimu- 
lants, massage, and fresh air. 



^ Dr. James G. Allen, of Philadelphia, used the Faradic current successfully in 
two cases. Dr. Lusk, of New York, considers this the best method. 



l66 DISEASES OF WOMEN. 



MOLE PREGNANCY. 



The true mole is always a product of conception ; in other 
words, it is a fecundated ovum which has been early blighted. 
Compressed clots of blood, polypi, shreds of mucous mem- 
brane, and genuine hydatids, have all been called by this 
name, but incorrectly. The disease, in most cases, consists 
in hyperplasia of the chorion, which assumes the form of 
small cysts filled with fluid and attached to each other by 
stalks. Gooch aptly compares the mass to '* myriads of lit- 
tle white currants floating in red-currant juice." When 
thrown off, the minute fcetus originally contained in its mem- 
branes has been dissolved in the liquor amnii and absorbed. 
Sometimes a small piece of the umbilical cord is left. The 
death of the embryo may be due either to disease origi- 
nating in its own tissues, or poison communicated mater- 
nally, as when the mother is affected with syphilis. Moles 
may also result from disease of the placenta or umbilical 
cord. 

The symptoms are rather obscure. The most prominent 
one is occasional or persistent hemorrhage. If the cervix is 
sufficiently patulous, a soft, placenta-like mass may be felt by 
the surgeon's finger. The size of the uterus does not corre- 
spond to the period of pregnancy, and the whole organ feels 
softer and more doughy than in normal gestation. The 
womb, after enlarging rapidly for a time, suddenly becomes 
stationary ; and the breasts become flaccid. But the diag- 
nosis is more easily made out after expulsion of a portion of 
the mass. 

The late Dr. Tyler Smith first directed attention to what 
he called missed labor, a very rare affection, in which the 
uterus fails to contract at term, and the child is retained an 
indefinite period, but is finally discharged piecemeal. 

Treatment. — If the uterus is large, and labor pains have 
commenced, ergot may be administered. But if the bleeding 
is severe the surest way is to dilate the cervix with the fin- 



Puerperal hemorrhage. 167 

gers or a water-bag, and extract the mass as soon as practi- 
cable. A small dose of ergot may be given after its re- 
moval. 

puerperal hemorrhage. 

This accident may be due to a number of causes, chief 
among which are the following : 

1. Abortion. 

2. Retained placenta. 

3. Placenta praevia. 
.4. Uterine relaxation. 

5. Concealed hemorrhage, from partial and premature 
separation of the placenta before labor or near its commence- 
ment. 

6. Varicose veins in the vulva or vagina. 

7. Inversion of the uterus. 

8. Lacerations of the uterus or vagina. 

The first form, and its treatment, have been already dis- 
cussed. The second, third, and fourth forms belong more 
properly to obstetrics than gynecology. In concealed hemor- 
rhage, blood may be poured out from the centre of the pla- 
centa while the edges remain attached. After a time bloody 
serum makes its appearance externally, the clot remaining in 
the uterus. The symptoms are those of shock, severe pain 
in the abdomen, followed by collapse. If labor has com- 
menced, the pains are either entirely suspended or become 
very feeble. 

Hemorrhage from rupture of varicose veins in the vulva is 
apt to be confounded with ordinary uterine flooding, and can 
be best detected by ocular inspection. Death may possibly 
result from this cause within a few minutes. The other two 
forms will be described under their appropriate headings. 

Treatment. — Separation of the placenta, entirely or par- 
tially, is the best rernedy in placenta praevia. When the 
hemorrhage proceeds from uterine relaxation after delivery, 
injections of hot water and tinct. iodine into the womb will 



l68 DISEASES OF WOMEN. 

generally arrest it. The undiluted tincture may be used if 
necessary. Vinegar is a good styptic, always at hand. Con- 
cealed hemorrhage can best be arrested by rupture of the 
membranes and emptying the womb, either by turning or 
application of the forceps. Pressure and styptics are the 
remedies for rupture of varicose veins. Monsel's or James' 
styptics may be used. The latter is prepared by saturating 
alcohol with powdered resin. 

In most cases, stimulants (brandy, ammonia) to keep up 
the heart's action, warmth to the feet, raising the lower por- 
tion of the bedstead so as to lower the patient's head, and the 
administration of ergot hypodermically, are indicated. But 
ergot should not be given until reaction has been established, 
and it is advisable to combine it with small doses (sixteen to 
twenty drops) tinct. nux vomica. 

The following (unpublished) case occurred in the practice 
of Dr. John M. Harlow, Woburn, Mass.: 

Case XXII. — Mrs. J., Burlington, Mass., thirty-five years 
of age, the mother of one child, when near her full term, 
December i6, 1871, lifted a heavy wash-boiler, and was sud- 
denly seized with faintness approaching to collapse. She was 
put to bed, stimulants freely administered, under the use of 
which she soon rallied, though still pale. There was no 
external evidence of hemorrhage, and the motions of the 
child could be distinctly felt. On the third day, symptoms 
of shock returned, followed by normal labor and delivery. 
The vertex presented. The child was still-born. The pla- 
centa was large ; the centre being covered by an immense 
clot, and only the circumference showed evidence of recent 
attachment to the uterus. She made a good recovery. 

PERSISTENT VOMITING. 

I do not refer to the mild ''morning sickness" so com- 
monly present during the early months of pregnancy. A 
moderate amount of nausea and vomiting, soon after concep- 



PERSISTENT VOMITING. 1 69 

tion, can only be classed as a sympathetic disorder ; but 
when it becomes persistent, and neither solids nor liquids can 
be retained in the stomach, it is really a disease. Primiparae 
are more apt to be affected than multiparae. In many cases 
the uterus is retroflexed or otherwise displaced. The in- 
stances of death from vomiting in the early months of gesta- 
tion are rare. Prof. Burns, in his '' Principles of Midwifery," 
states that he has never known death to result from vomiting 
dependent on pregnancy alone. Dr. Bixby, of Boston, says 
that in the large Lying-in-Hospital of Vienna, cases of this 
kind are so rare that a student may attend for years without 
seeing one. 

Treatme7it. — Like other intractable diseases, the remedies 
confidently recommended for it are almost innumerable. If 
the disease is not very severe, the patient may be ordered to 
breakfast in bed, and remain there for one or two hours after 
eating. A few subcutaneous injections of morphia acetate 
(gr. i^) may be tried. Prof. Burns recommends the applica- 
tion of leeches to the epigastric region. 

If caused by displacements of the womb, abrasion or lacera- 
tion of the cervix, a dislocated or inflamed ovary, or disease 
of the brain, special treatment of these organs will be neces- 
sary. A pessary skilfully inserted sometimes relieves the 
distressing symptoms at once ; iodide of phenol or extract of 
belladonna, applied to the raw cervix, have given relief; and 
a series of small blisters externally have at the same time 
cured the ovaritis and hyperemesis. Oxalate of cerium, 
hydrocyanic acid, nitrate of bismuth, and creosote, have each 
been extravagantly lauded. As articles of diet, raw-beef juice, 
iced milk, onions, or raw bacon, are most likely to be retained. 
Benefit has also been derived from iced champagne wine. 

When these measures fail it is well to give the stomach a 
rest for several days, and try rectal alimentation. Administer 
a single ounce of milk, clear soup, raw-beef juice, or ox-blood 
by the rectum every hour. If retained, the quantity may be 
gradually increased at longer intervals. There is good reason 



170 DISEASES OF WOMEN. 

to believe that when successful a reversed peristaltic motion 
occurs, carrying the injected food even into the ileum and jeju- 
num, where it is partially digested and absorbed. 

The late Dr. Copeman, of Norwich, England, first sug- 
gested dilating the cervix digitally to arrest persistent vomit- 
ing. I have tried his plan in five cases, two of which proved 
successful, without being followed by abortion. It is worthy 
of further trial. 

But if the disease remains unsubdued, after faithfully em- 
ploying the milder remedies, it will be necessary to empty 
the uterus by one of the methods already detailed under the 
head of puerperal convulsions (p. 149). 

Case XXIII. — Mrs. P., an American lady, residing in 
Maiden, Mass., twenty-six years of age, had been married 
thirteen months. In February, 1869, about five months after 
her marriage, she miscarried of a two-months foetus, and 
never entirely recovered from this sickness. Some time in 
the following June she again became pregnant ; she was able 
to go about, but was not in good health. About the middle 
of September, vomiting set in, and continued with brief inter- 
missions till her death four weeks later. 

I saw her for the first time October nth, four days before 
she died. During her sickness in February, and in the early 
part of her last illness, she was attended by a homoeopathic 
practitioner. My prognosis from the first was unfavorable. 
The usual remedies — ice, hydrocyanic acid, creosote, etc. — 
had all been tried with but temporary benefit. I proposed a 
consultation with Dr. H. R. Storer, with a special reference 
to the propriety of producing abortion as a last resort. Dr. 
Storer saw her on the 13th ; he thought more favorably of her 
chances for recovery, and the operation was not performed. 
Labor pains, however, set in about 2 o'clock on the morning 
of the 14th ; the foetus was expelled at 7 A.M., convulsions and 
coma supervened, and terminated the scene two hours later. 

One thing remarkable was the absence of emaciation. This 
was evident during life, but still more so at the autopsy. My 



PTYALISM. 171 

unfavorable prognosis was founded on the rapidity and Irregu- 
larity of the pulse, the excessive thirst, the color and pecu- 
liar appearance of the matters vomited, and the expression of 
the countenance, which betokened exhaustion. 

An autopsy was made by Dr. Bixby thirty hours after 
death. The stomach was nearly empty, somewhat reddened, 
but not organically diseased. The uterus bore marks of 
inflammation, the mucous coat being dark-colored, almost 
black, and highly congested. A few slight shreds of the pla- 
centa remained attached to the fundus. The kidneys were of 
a bluish-black color, and quite friable. The urine was exam- 
ined twice ; no albumen was detected In it. 

PTYALISM. 
Profuse salivation during pregnancy Is not a common dis- 
ease ; but when It does occur it proves very distressing. It 
generally commences early, and seldom continues longer than 
two months. The quantity varies from a pint to four quarts 
during twenty-four hours. 

TreaU7tent. — Continuous pellets of Ice, tamarind water, or 
mild astringents, after a short time, generaUy control excessive 
flow of saliva. Dewees gives the details of a case, commen- 
cing in the second month, who "■ discharged daily from one to 
three quarts of saliva, and was at the same time harassed by 
incessant nausea and frequent vomitings." She was finally 
cured by being limited to a strictly animal diet, with small 
doses of laudanum night and morning. Dr. Thomas Skinner, 
of Liverpool, recommends the following : 

]^ . Alumlnls sulphatis 3 iss. 

Magnesiae sulph 3 lij. 

Acidi sulph. diluti 3 iij. 

TInct. opil = 3 ss. 

Mist, formyli concent.* ad. | vi. 

M. S. A dessertspoonful 3 t. d. after meals in a small glass 
of water. 

1 Made by agitating a drachm of chloroform in a pint of water. 



T2 DISEASES OF WOMEN. 



PUERPERAL LACERATIONS. 



There are four well-marked forms of tearing during deliv- 
ery, namely, laceration of the cervix, rupture of the uterus, 
rents in the vagina or vulva, and laceration of the perineum. 

Laceration of the Cervix, to a slight extent, is a com- 
mon occurrence among primiparae, and requires no special 
treatment except when it gives rise to reflex symptoms (see 
p. 73). More rarely the rent extends to the internal os, 
and results in puzzling post-partum hemorrhage. Still more 
rarely the uterine tissues are so bruised and stretched that the 
whole cervix separates transversely and comes away. In 
many cases the rent does not include the peritoneal coat. 

Rupture of the Uterus. — Sudden rupture of the womb 
is a serious accident. The tear generally commences near 
the cervix, proceeding obliquely upward, and the child passes 
into the abdominal cavity. The patient utters a piercing- 
shriek as she feels an unusual pain, and the labor pains sud- 
denly stop ; the pulse becomes rapid and feeble ; nausea and 
vomiting follow, perhaps syncope. If, on making a vaginal 
examination we find that the child has receded out of reach, 
while blood flows freely from the vagina, we may be sure that 
rupture of the uterus has taken place. If the child's head 
has become impacted there will be no recession. Occasion- 
ally the rupture is more gradual, and the symptoms of shock 
less pronounced. 

Treatment. — If a part of the child still reifiains in the 
womb, delivery may be effected by turning; but if it has en- 
tirely passed into the abdominal cavity, the Caesarean section, 
performed with antiseptic precautions, is preferable. Stitches 
in the uterus itself are rarely needed. Stimulants require to 
be freely administered. Peritonitis is likely to supervene, 
and should be prevented, if possible, by absolute rest, evap- 
orating lotions, opiates, and the regular use of the catheter. 

Lacerations of Vagina or Vulva. — Slight rents con- 
fined to the mucous membrane are not of much consequence. 



PUERPERAL LACERATIONS. 1/3 

But when the tear is complete and occurs in the upper part 
of the vagina the symptoms are very similar to rupture of the 
uterus and require like treatment. After delivery it is well 
to insert stitches of catgut. Lacerations of the vulva between 
the clitoris and urethra are generally followed by dangerous 
hemorrhage. This is best controlled by a small sponge 
dipped in hot water and pressed on the bleeding spot, or by 
a pledget of absorbent cotton dusted with Monsel's styptic, 
applied under a pad and kept in place by a T-bandage. If 
the vessel is superficial an acupressure needle will readily 
control the bleeding. 

Lacerated Perineum. — There are several grades of this 
injury, ranging from a simple tear of the anterior border to 
laceration of the whole septum between the rectum and 
vagina. The slighter degrees may be cured by simple attention 
to rest and cleanliness ; those which include tearing of the 
perineal body and rupture of the sphincter ani are exceed- 
ingly difficult to manage. The accident is more apt to occur 
in primiparae. 

When the perineal body has been completely severed, 
the tendency to uterine prolapse is imminent ; the vagina 
remains more patulous than it should be, admitting air at all 
times, and ultimately the lower part of the mucous membrane 
becomes so much altered by exposure that it looks like ordi- 
nary cuticle. The perineum may be lacerated on the vaginal 
surface, tearing the perineal body without involving the 
skin, and this results in about as much mischief as when the 
tear is complete. Cases have occurred where the child's 
head made a hole in the centre of the perineum, leaving the 
fourchette and the sphincter ani unruptured. To avoid 
laceration of the perineum, when midwifery forceps is used, 
it is better to remove the instrument before the head 
emerges. 

Treatment, — When detected immediately after delivery 
(and an examination should always be made with that object 
in view) the parts should be washed with hot water, and deep 



174 DISEASES OF WOMEN. 

interrupted stitches inserted. At that time the tissues are 
benumbed, and the pain of the operation is very sh'ght. If not 
attended to immediately, four months or more should be al- 
lowed to elapse before operating. The patient is etherized, 
placed in the lithotomy position, two assistants supporting the 
flexed legs and separating the labia. The operator denudes 
the requisite amount of surface with scissors, and, after all 
bleeding has ceased, sutures of iron or silver wire are deeply 
inserted. Dr. Emmet uses a straight round needle with a 
large eye. The operator's index finger should be passed 
into the rectum to guide the needle and protect the intestine. 
The sutures are removed on the seventh day. Full details 
may be found in Dr. Emmet's invaluable work on Gyne- 
cology. 

The after-treatment consists in keeping the patient in bed 
for eight days, her knees tied together, with a folded napkin 
between them, and the bladder emptied every four hours 
with a flexible male catheter, taking especial pains not to 
allow urine to dribble on the newly united perineum, which 
may be further protected by covering with vaseline. When 
the sphincter ani has been torn. Dr. Sims recommends the 
retention of a large soft catheter in the rectum for several 
days after the operation. The knees should be kept tied to- 
gether at night for two weeks after removal of the sutures. 
At the end of eight days an injection of warm olive oil will 
promote an evacuation of the bowels. The perineum should 
be supported during defecation for- some time, and constipa- 
tion must be carefully avoided. 



RELAXATION OF PELVIC JOINTS. 

During gestation a normal relaxation of the pubic and 
sacro-iliac articulations occurs. This is more marked in some 
women than in others, especially during the last four months 
of pregnancy. The cartilaginous surfaces of these joints be- 
come softened and spongy by serous infiltration ; they are 



COCCYODYNIA. 175 

therefore thicker than before, and the pelvic cavity is slightly 
enlarged.' This process of infiltration and thickening may go 
on to such an extent as to cause serious relaxation of the 
joints, especially at the pubic symphysis and at one or other 
of the sacro-iliac articulations, with almost total loss of the 
power to walk. Sometimes the relaxation is not noticed till 
several weeks after delivery. 

The diagnosis is best arrived at by examining the patient 
on a table in the horizontal position. Undue mobility at the 
pelvic symphysis may be detected by moving the ossa in- 
nominata on each other at the mons veneris. If either sacro- 
iliac joint is relaxed, first fix the spine, and move the haunch- 
bone with your hand. Or fix the haunch-bone first, and ask 
the patient to move her spine. The prominent symptoms 
are pain in the joints affected, and inability to walk, or great 
difficulty in walking. 

Treatment. — The best, and, indeed, the only remedy, is 
the application of a firm, unyielding binder around the pel- 
vis. In slight cases, a piece of stout woollen webbing may 
suffice ; but in some a padded leather binder with straps and 
buckles will be necessary. Rest for a few weeks in bed is 
also indispensable. 

COCCYODYNIA. 

This aff"ection was first described by the late Sir James 
Simpson. It is mainly a neuralgia of the sacro-coccygeal 
joint, complicated, in some cases, with inflammation of the 
ligaments. The most prominent symptom is pain on sitting 
down, or pain during defecation. There are many degrees 
of this pain — from dull discomfort to perfect agony. Some- 
times the patient can only sit on one hip, resting on the edge 
of a chair, and the pain is renewed on rising. The pain is 



^ See Dr. J. Matthews Duncan's interesting chapter on this subject in his 
Researches in Obstetrics, p. 139. 



176 DISEASES OF WOMEN. 

aggravated by pressure with the hand or by distention of the 
bowels. 

Treatment. — This consists in free subcutaneous section of 
the muscles and tendons attached to the coccyx, under anti- 
septic precautions. In severe cases it may be necessary to 
remove the coccyx entirely. 



THROMBOSIS AND EMBOLISM. 

A uterine thrombus is most apt to form at the site of the 
placenta or its immediate neighborhood. Thrombi are more 
apt to occur in veins and lymphatics than in arteries. If the 
blood becomes decomposed, blood-poisoning results, evi- 
denced by severe chills, night-sweats, loss of appetite, and 
sometimes jaundice. Thrombus of the vulva is most likely 
to occur during or after delivery. This is really a haemato- 
cele, the vessel being ruptured, and the blood poured into 
the cellular tissue. In true thrombosis the blood coagulates 
in the vein. When a portion of this coagulum is washed 
away by the blood-current, and arrested elsew^here, it consti- 
tutes embolism. Sudden death, within a few days after de- 
livery, sometimes occurs from embolism of the pulmonary 
artery. The symptoms are those of shock, with severe dysp- 
noea, cyanosis, dread of death, and unnaturally low tempera- 
ture. Entrance of air into the uterine veins is attended with 
similar symptoms, and requires a like treatment. 

Treatme7it. — Absolute rest, stimulants, dry cupping over 
the chest, and concentrated food. Ammonia has been ad- 
ministered with a view to solution of the clot. 

Case XXIV. — A lady of nervous temperament, aged 
twenty-nine, was confined, for the third time. May 20, 1879, 
and delivered, by Dr. Minot, of twins. Profuse hemorrhage 
followed, but ceased in fifteen minutes. Pulse 120. After- 
pains severe. The patient was very oedematous, the urine 
abundant and albuminous. The lochia were abundant, and 



THROMBOSIS AND EMBOLISM. 1 77 

at times highly offensive. She kept her bed till the twentieth 
day after confinement, and was then only moved to a lounge. 
Four days later, at 3.15 P.M., on returning to the lounge 
after having sat on the vessel to urinate, she uttered a loud 
cry, and fell back with slightly convulsive action. When 
seen at 3.30 P.M. she was faint, and complained of pain In the 
cardiac region and Inability to breathe. Pulse 144, feeble ; 
respiration 36. Extremities cold ; sounds of heart feeble, 
but without murmur. Brandy and carbonate of ammonia 
were given at frequent Intervals. At 9 P.M. the pulse was 
160, and acute pain was complained of over the lower lobe of 
the right lung posteriorly. Cyanosis was soon after noted, 
and twenty-six hours after the seizure she died, the last two 
hours of life being free from pain. 

An autopsy was made twenty-three hours after death by 
Dr. Cutler. Emboli were found in each lung. The source 
of the emboli was a thrombosis of the ovarian vein, plexus 
pamplniformis, and uterine sinuses on the right side.' 

^Abridged from Proceedings of the Boston Soc. for Med. Observation, Nov., 
1879. 

12 



CHAPTER XVII. 
VAGINAL FISTULA. 

A GREAT many varieties are mentioned by authors, but 
they all may be included under two heads, namely, those 
which communicate with the bladder — vesico-vaginal — and 
those which enter the bowel — entero-vaginal fistulae. We 
can recollect the time when these accidents were the oppro- 
brium of surgery ; but, thanks to Drs. Sims and Emmet, this 
disgrace has been removed. It is mainly to Dr. Sims that 
the surgical world is indebted for persevering under the most 
adverse circumstances, one of his colored patients having 
been operated on thirty times before he succeeded ! As Dr. 
Emmet has pointed out, all the essential steps of the opera- 
tion, as at present performed, had been used by difterent 
surgeons many years before Dr. Sims operated, but he it 
was who rescued them from oblivion, and enforced, both by 
word and action, the feasibility of the operation. Dr. Boze- 
man, of New York, is also entitled to much credit for his zeal 
and industry in this connection. He uses an ingeniously con- 
structed table, on which the patient is fastened. 

VESICO-VAGINAL FISTULA. 

In the great majority of cases this accident results from im- 
paction of the head during delivery. The part most severely 
pressed upon sloughs in the course of eight or ten days, 
leaving a hole in the bladder of variable size and position, 
through which the urine constantly dribbles away. It is 
possible, but not probable, that a fistula may be produced 



VAGINAL FISTULA. 179 

by the bungling use of forceps, the parts behig torn, and a 
ragged opening the immediate result. One case is men- 
tioned where a raw medical student opened the bladder with 
his lancet in an effort to puncture the membranes. Fistulae 
may also be formed in uterine cancer (the disease spreading 
to the vagina), from phagedenic syphilis, from impacted stone 
in the bladder, and sometimes from a neglected pessary. 

The diagnosis is generally easy. While the left forefinger 
is in the vagina, pass a silver catheter into the bladder, and 
the fistula, if as large as a pea, will readily be detected. In 
very small fistulae it will be necessary to expose the parts 
with a Sims speculum, and inject colored water through the 
urethra ; or, instead of water, smear the vaginal roof with 
thin boiled starch, and slowly inject a weak solution of 
iodine, when the seat of the injury will be revealed by a blue 
color. 

The main symptom is inability to retain urine. The water 
dribbles away all the time, leaving a deposit of phosphates in 
the vagina, with irritation and excoriation of all the adjacent 
parts. Non-retention is generally noticed within two weeks 
after delivery. This state of things must not be confounded 
with paralysis of the sphincter vesicae, a somewhat rare affec- 
tion, in which, from stretching or long-continued pressure 
during labor, temporary incontinence results ; the urine runs 
off continuously, but there is no fistulous opening. Fistula 
from cancer is incurable. 

Treatment, — This may be divided into two stages, namely, 
preparatory and operative. Dr. Emmet rightly attaches the 
greater importance to the first. He can only recall two in- 
stances where women were sent to the hospital with this lesion 
immediately after delivery. In both of these cases the fistula 
closed within a month, having had no treatment but warm 
water injections, and were discharged cured without an opera- 
tion. Want of cleanliness is the chief reason why the same 
result does not follow in most moderate-sized fistulae, more 
especially in those rare cases where the injury is produced by 



l80 DISEASES OF WOMEN. 

midwifery forceps. The patient should keep up, and empty 
her bladder every two hours or oftener. 

In old, neglected vesico-vaginal fistulae, the first step is to 
remove the phosphatic deposit with a soft sponge, brushing 
over the raw surfaces with a we^k solution of silver nitrate. 
In some cases it is necessary to use a strong solution or even 
the solid crayon. Warm sitz-baths are useful after each appli- 
cation. The excoriated parts are then dried, and smeared 
with vaseline, which protects them from the urine. Napkins 
used to absorb the flow should be washed and dried, not dried 
only, before being used again. 

Cicatricial tissue should be snipped with scissors, two fingers 
of the left hand being kept in the rectum, a Sims glass dilator 
inserted in the vagina, and kept in place with a T-bandage. 
This helps to arrest bleeding, and also promotes absorption. 
To prevent phosphatic deposit as much as possible : 

5. Sodium biborate 3iij. 

Water ^ xij. 

Benzoic acid 3 ij. 

M. Sig. Dissolve the borax in the water, and add the acid. 
Give a tablespoonful in half a tumblerful of water 4 t. d. 

It is essential to success that the indurated edges of the fistula 
should be softened by successive applications, until the tissue 
presents a natural color and consistence. 

I do not propose to give a detailed account of the opera- 
tion. That can best be learned by seeing some competent 
surgeon operate. The following are the main points : the 
bowels are to be thoroughly cleared the day before by a 
cathartic, and on the morning of the operation administer a 
copious injection of warm soap-suds. The patient should 
be completely etherized. Ascertain that the surfaces can 
be approximated without undue tension. Denude the edges 
carefully with scissors, in a continuous strip if possible, be- 
ginning at the lowest point. Do not cut the mucous mem- 



VAGINAL FISTULA. l8l 

brane of the bladder, or include it in the stitches. Avoid 
wounding the ureters. Use metallic sutures, which are gen- 
erally removed on the eighth or tenth day. Sims' sigmoid 
catheter, made of hard rubber, is kept in the urethra for 
about two weeks, and frequently cleaned. The patient's 
legs are flexed and supported on a double-inclined plane, 
properly padded. Opium is given daily until the sutures are 
removed. 

Case XXV. — Mrs. C, twenty-two years of age, of Irish 
birth, and very stout, was attended in her first labor, at 
Stoneham, Mass., by an incompetent midwife, who allowed 
the child's head to become impacted for two days before 
acknowledging her inability to effect delivery. Dr. Stevens 
and the writer took charge of the case on the third day, July 
lO, 1871, and immediately performed craniotomy. The parts 
sloughed on the tenth day after delivery, leaving a vesico- 
vaginal fistula in the base of the bladder, near the neck, large 
enough to allow a female silver catheter to pass through. 
Mrs. C. was twice operated upon in Boston, unsuccessfully, 
and was finally cured in a single operation by Dr. Emmet at 
the New York State Woman's Hospital. She has since given 
birth to two living children at full term without accident. 

ENTERO-VAGINAL FISTULA. 

The rectum is generally the seat of this accident; although 
almost any portion of the small intestines may ulcerate 
through and communicate with the vagina. Recto-vaginal 
fistula generally follows impaction, but may be the sequel of 
cancer or syphilis. When located near the sphincter ani, this 
muscle must be paralyzed before operating. If complicated 
with stricture of the rectum there is good ground to suspect 
syphilitic infection, in which case any operation would neces- 
sarily prove a failure. If the fistula is small, gas or liquid 
faeces only pass through, and sometimes a flap forms on the 
rectal side, which acts as a valve. 



1 82 DISEASES OF WOMEN. 

Treatment. — Substantially the same as for veslco-vaginal 
fistula. At least as much pains should be taken to bring the 
tissues into a healthy state before operating. It is more 
difficult to close a recto-vaginal fistula from the vaginal side 
than to cure a vesico-vaginal one, because the opening is 
larger on that side and the edges much bevelled. 

Give a purgative the preceding day, and wash out the 
bowel and vagina thoroughly, two hours before the operation, 
with warm water. Paralyze the sphincter by stretching the 
anus with the thumbs, and insert a sponge, with string at- 
tached, in the rectum as high as the sigmoid flexure, to pre- 
vent the passage of faeces during the operation. Place the 
patient in the extreme lithotomy position, keep the vulva 
open with wire retractors, freshen the surface carefully with 
scissors, and, after all bleeding has stopped, insert silver-wire 
stitches. When the fistula is small, it may be operated 
on from the rectal surface ; although there is generally 
more trouble from bleeding, and failure from non-union is 
more likely to occur on that side of the fistula. The sponge 
is withdrawn before she is put to bed; the stitches maybe 
removed on the eighth day. Injections to move the bowels 
should not be administered. 

The following (personal) case is interesting on several ac- 
counts. 

Case XXVI. — Mrs. C, Peabody, Mass., aged twenty -nine. 
She had suffered from dysmenorrhcea when a girl. Had been 
married seven years ; no child, nor miscarriage. She noticed 
that air passed audibly from the front passage as early as 
October, 1877. Three months later small quantities of liquid 
faeces passed into the vagina at short intervals. 

A consultation was held with Dr. Baker, of Boston, March 
9, 1878. The patient was thoroughly etherized, and the fis- 
tula exposed by nieans of a Sims speculum and retractors. 
Fecal matter was detected issuing from the fistulous orifice, 
which was only large enough to admit a small silver probe ; 



VAGINAL FISTULA. 1 83 

the probe passed about four inches. No treatment was at- 
tempted at the time ; but six days later, with the assistance 
of Dr. Stevens, she was again etherized, and a weak solution 
of iodine injected into the fistula. The same process was re- 
peated at her home in Peabody on March 30th and April 7th. 
As these injections (of increasing strength) did not seem to 
produce any effect in lessening the discharge, at the next 
visit, April 22, ii A.M., a weak solution of chromic acid was 
injected. As on former occasions, the administration of 
ether was followed by a fit of vomiting which this time was 
more severe and continued longer than usual. Dr. Pike, of 
Peabody, was sent for and gave morphia (gr. J) hypoder- 
mically to reheve the pain and nausea. This was partially 
successful; but she never fully rallied, and died at midnight, 
thirteen hours after the original injection. 

Next forenoon, Dr. Pike made a careful autopsy, and the 
following is substantially his report : '* At a point just imrhe- 
diately below and involving the sigmoid flexure of the colon, 
the gut was somewhat displaced and was glued by inflamma- 
tory deposits at a point contiguous to the posterior part of 
the vagina. The intestine was perforated, and, lodged in the 
adjoining cellular tissue, about thirty grape-seeds were found 
in a bed of pus. A small sinus could be traced from the pos- 
terior vaginal wall to the ileum. No chromic acid was present 
in the sac containing the grape-seeds ; but the vagina and 
ileum were stained by it." 

Suppuration had evidently been going on in the sac for 
several days ; and her husband declared that she had not 
eaten any grapes for at least a week. The violence of the 
retching had resulted in rupture of the sac, prostration, and 
death. Peritonitis had evidently set in, but could scarcely be 
set down as the cause of death. 



CHAPTER XVIII. 
DISEASES OF BLADDER AND URETHRA. 

CYSTITIS. 

This is a very common affection in women, especially the 
milder forms. Authors divide it into acute and chronic cys- 
titis, according to the severity and duration of the symptoms ; 
but a really acute case is rarely met with. Cystitis may be 
caused by a blow over the pubis, pressure of the child's head 
during labor, instrumental delivery, displacements of the 
womb, insertion of foreign bodies into the bladder, over-dis- 
tention, gonorrhoea, constitutional diseases which affect the 
integrity of the lining membrane, certain drugs (cantharides 
or turpentine), and exposure to cold. The last-mentioned is 
a kind of catarrh. 

The patient passes water frequently, and has a desire to do 
so still oftener. Micturition is attended with tenesmus and 
pain, often amounting to agony. There is generally a dull 
pain over the pubis, which is apt to extend to the back and 
perineum. In chronic cases the urine is usually alkaline, the 
alkali being some salt of ammonia. The sediment consists 
of mucus and pus, the latter of which may become gelatinized 
by contact with ammonia. In old cases, the urine is ropy, 
clinging to the vessel, and even to the urethra during its pas- 
sage, and is commonly mixed with blood. Albumen is al- 
most always present. 

At first the mucous membrane is congested and inflamed, 
finally becomes ulcerated and peels off in patches. In very 



CYSTITIS. 185 

bad cases, the inflammation and ulceration extend to the 
muscular coat, and may even eat through the peritoneal coat, 
ending in general peritonitis. The mouths of the ureters 
participate in these changes, and are often partially occluded, 
so that there is a tendency to dam up the urine, exerting a 
backward pressure, and disorganizing one or both kidneys. 
From continuous straining during over-distention a fissure is 
apt to form at the neck of the bladder, and the tissue there is 
very much hypertrophied. This thickening may extend to 
the whole viscus, reducing its capacity so that in some cases 
it can barely hold a tablespoonful. 

Treatment. — The first indication is to render the urine as 
bland and unirritating as possible ; and this is best effected 
by the free use of soothing drinks, such as slippery-elm tea, 
infusion of triticum repens, buchu, or milk and water. Milk 
is the best food, and patients have sometimes been cured by 
rest and a milk diet. Other articles, mostly in a fluid form, 
may be allowed — plain soups, beef-tea, egg-and-milk, and flour 
porridge. At the same time the bowels should be kept open 
by sodium phosphate or some other saline laxative. The skin 
must be brought into an active state by diaphoretics if neces- 
sary. Opiates should be employed sparingly, if at all. To 
relieve pain, give sodium bromide or ammonium bromide in 
plenty of water. Dr. Skene, who has had great experience 
in such cases, recommends an aqueous solution of hydrobro- 
mic acid for the same purpose. Neutral benzoate of ammonia, 
recently prepared, is an excellent remedy (dose, gr. xii. to 
gr. XX.). Like the rest it should be given in plenty of water. 
Cures have been effected by administering balsam copaiba, 
followed by mild alkaline drinks. 

In addition to these internal medicines, the bladder should 
be washed oiit at least twice a day with a tepid solution of 
common salt or one of borax. The best instrument for this 
purpose is the douche-pail, already described (p. 40). The 
terminal glass tube is removed, and a double catheter, with 
numerous small holes at the distal end, attached in its place. 



1 86 DISEASES OF WOMEN. 

This is warmed, anointed with vaseline, and gently inserted in 
the urethra. Not more than two ounces should be allowed 
to enter the bladder at first ; and, if an old chronic case, one 
ounce will be sufficient, for the bladder should be very gradu- 
ally dilated. Cork the exit tube of the catheter, and retain 
the injection for ten minutes. Then remove the cork, and very 
slowly continue the injection up to four ounces, which should 
be retained as before. After a few days a continuous stream 
may be employed, but always slowly. Great care, too, 
should be taken that the posterior wall of the bladder is not 
allowed to impinge forcibly on the catheter toward the end 
of the washing. To avoid this, moderate the flow by pinch- 
ing the rubber tube, and withdraw the catheter before the 
bladder is quite empty. 

' With some practitioners a solution of silver nitrate is a 
favorite remedy. Prof. Gouley says : *' If a strong solution 
is used, employ only a few drops ; and if a large injection is 
made, the solution should be mild." Lead acetate, zinc sul- 
phate, or potassium permanganate, may be used instead of 
the lunar caustic. I have derived most benefit from the 
permanganate. After an injection of any kind, even of tepid 
water, the pain is sometimes increased, and if so it is well to 
throw in a small dose of morphia in solution to allay pain. A 
healthy bladder is the least absorbent of mucous surfaces ; 
but the abraded membrane takes up the anodyne more read- 
ily. As a general rule injections should be tepid. 

If all these remedies fail, and in some desperate cases they 
do, we have one resource left, an artificial vesico-vaginal fis- 
tula ; in this way we may give the bladder perfect rest. We 
are indebted for this suggestion, and the necessary directions, 
to Dr. Emmet. Before operating, find out that the kidneys 
are not seriously diseased, by a chemical and microscopical 
examination of the urine. If the kidneys are involved, do 
not give an anaesthetic ; for in such cases death is liable to 
result from uremic poisoning ; and it is safer to administer 
opium to dull the pain of the operation. It is also necessary 



CYSTITIS. 187 

to ascertain that it is the bladder, and not the urethra alone 
which is affected. 

The following are the principal steps. A steel sound, such 
as is used in searching for stone, is introduced into the blad- 
der, and firmly pressed in the median line against the base 
by an assistant. The projecting tissue is raised by a double 
tenaculum, and divided with scissors on the point of the 
sound until the latter emerges, when one blade of the scissors 
is inserted, and the whole septum cut backward for half or 
three-quarters of an inch. As the mouths of the two ureters 
and the proximal end of the urethra form the boundaries of 
a triangle about one inch equidistant, care must be taken 
not to injure these openings. The principal blood-vessels lie 
outside of the ureters, so that there is but little risk of hem- 
orrhage. After the artificial fistula has been made in this 
way, the great trouble is to keep it patent. Dr. Emmet ad- 
vises the careful introduction of a clean finger night and 
morning for a few days at first, and afterwards inserts a glass 
eyelet made like a shirt-stud ; it should be made of flint glass 
without any admixture of lead, to prevent phosphatic de- 
posits, and requires to be frequently cleaned. Dr. Bache 
Emmet's fistula tube, for the same purpose, has the advan- 
tage of carrying the urine to the vaginal outlet like a 
catheter. 

The after-treatment consists in washing out the bladder 
once a day w-ith lukewarm water containing a small quantity 
of potassium permanganate. The douche-pail, with a small 
glass nozzle introduced per urethra, and a rubber bed-pan to 
receive the water, answers very well. Or a common David- 
son syringe may be used. Stimulating or spicy articles of 
diet must be eschewed, and fermented liquors totally ab- 
stained from. 

Case XXVIL — Mrs. Kate C, a large, heavy woman, 
thirty-seven years of age, has been twice married ; never had 
any children, never miscarried. Has lived with her present 



1 88 DISEASES OF WOMEN. 

husband ten years. First complained of severe pain in the 
bladder nine years ago. Was attended by the late Dr. 
Stevens, of Stoneham, and by Dr. French, of Canada East, 
for two years, without much benefit. Then came under the 
author's care for about six years. Her case was diagnosti- 
cated as chronic cystitis, much aggravated at times by errors 
of diet. No suspicion of a syphilitic taint. During the first 
two years lunar caustic had been freely used and many other 
remedies tried. 

The treatment employed after she came under my care was 
chiefly dietetic, along with frequent injections of bland fluids, 
such as weak solution of borax or potassium permanganate. 
The urethra was also inflamed, to which a plasma of lead 
iodide was applied. She took buchu tea, infusion of triticum 
repens, and at one period potassium iodide internally. The 
distressing pain was allayed with hyoscyamus, valerianate of 
ammonia, and potassium bromide, in small doses. For this 
purpose, hot sitz-baths were also frequently employed. 
Sometimes for months the disease would be apparently mas- 
tered and the patient would enjoy an interregnum of comfort. 
But some error of diet or pernicious indulgence would light 
up the flame again, and in a single day all the old pains would 
return. 

Finally, she was induced to enter the Massachusetts Gene- 
ral Hospital, May 9, 1878, and on the i6th Dr. J. Collins 
Warren made an artificial fistula. A second operation was 
performed in October following, and instead of a glass stud 
the edges of the opening were retracted, the adjoining sur- 
faces freshened, and silver-wire stitches inserted. By this 
plan the opening was kept patent for about two years, and 
great relief afforded. The opening was finally closed Sep- 
tember 24, 1880, resulting in a complete cure. The patient 
reported herself at my office in June, 1881, with no return of 
the disease. 

Dr. Alfred C. Post has employed the actual cautery for 



STONE IN THE BLADDER. 1 89 

relief of cystitis, by making two small eschars over the pubis 
with an iron knob at a red heat. 



STONE IN THE BLADDER. 

This is a rare affection in women,, occurring at least twenty 
times in men for once in women. On account of the short- 
ness of the female urethra and its great dilatability, calculi of 
considerable size are sometimes voided spontaneously. In 
most cases, a stone in the female bladder may be readily 
detected by pressing a finger in the vagina against the supe- 
rior wall, wqth the other hand depressing the bladder above 
the pubis ; or by sounding in the usual way with a short- 
beaked steel bougie. The patient should be placed in the 
dorsal position, with the pelvis elevated and the bladder 
half full of water. One of the diagnostic signs is dilatation 
of the meatus urinarius. Sometimes a stone becomes en- 
cysted. 

Treatment. — If the stone is small and smooth, it may be 
removed through the urethra after gradual or rapid dilatation. 
If large or rough, it is better to employ litholapaxy, a modifi- 
cation of lithotrity ; or make an incision at the base of the 
bladder, a kind of lithotomy. 

Litholapaxy — for which we are indebted to Prof. Henry J. 
Bigelow — consists in crushing the stone with a lithotrite, and 
removing the fragments at one sitting by means of an elastic 
bulb, a large canula, and a trap receiver. The apparatus is 
expensive, and needs an experienced operator to handle it 
safely. More difBculty is met in retaining a sufficient quan- 
tity of water in the female than in the male bladder, and con- 
sequently, the mucous lining is more apt to be caught in the 
jaws of the lithotrite. 

The vesico-vaginal cut, originally described by Chelius, is 
preferable in those cases where the coats of the bladder have 
become thickened, and especially where cystitis also exists. 
The incision should always be longitudinal. Dr. McClintock, 



I90 DISEASES OF WOMEN. 

of Dublin, recommends us to make the cut transversely ; but 
such an incision could scarcely avoid wounding one or both 
ureters, the space between their termination being only one 
inch. The operation is identical with that used in the radical 
cure of cystitis, already described. If cystitis is not present, 
the wound may be closed with v/ire sutures as soon as the 
bleeding ceases. 

URETHRITIS. 

This disease is closely allied to cystitis in its nature, symp- 
toms, and treatment. When the bladder is not also inflamed, 
the vagina is apt to be so, as in gonorrhoea. A moderate 
degree of urethritis is common in most married women who 
are affected with uterine disorders ; and it is always well to 
make inquiries about this matter, and take steps to relieve 
the inflammation, which otherwise might end in cystitis. 
Pain in passing urine, with a scalding sensation afterward, 
are the main symptoms. The desire to urinate frequently is 
not as great as in cystitis, but the pain during and imme- 
diately after micturition is often more severe. Small quanti- 
ties of blood generally pass with the first portions of urine. 
The meatus looks inflamed, and is sometimes smeared with 
pus. Pressure on the urethra from behind forward will, in 
such cases, discharge a little bloody pus. Urethritis, espe- 
cially in old people, may be complicated with granular ero- 
sion, which greatly aggravates the pain during micturition 
and the tenesmus which follows. 

Treat^nent. — For mild, recent cases use warm sitz-baths, of 
which four of an hour's duration each should be taken daily. 
While in the bath, inject eight or ten drops bismuth liquor 
into the urethra. Direct a stream of hot water on the meatus ; 
and, if pus is present, wipe out the passage by means of a 
probe wound round with iodized cotton. Injections of a tepid 
solution potassium permanganate, administered through Dr. 
Skene's reflux catheter, are useful. Injections of hot water 
{iio° to 120°) through the same instrument, which is passed 



URETHRAL TUMORS. I9I 

up to the neck of the bladder, may be given at bedtime. In 
chronic cases much benefit is often derived from gradual dila- 
tation with bougies. The internal remedies prescribed for 
cystitis are also indicated in this affection. The best is bal- 
sam copaiba in capsules. A suppository of belladonna and 




Skene's Reflux Catheter. (Munde's "Minor Gynecology," p. 



morphia, introduced into the vagina at bedtime, will give the 
patient a better chance to procure a good night's rest. 

When urethritis is complicated with granular erosion, the 
urethra should first be dilated, and the surface freely swabbed 
with cotton wound round a probe and dipped in strong iodide 
of phenol. 

URETHRAL TUMORS. 

Modern writers describe eight or ten different kinds of ure- 
thral tumors, all of which, with the exception of that com- 
monly called caruncle, are exceedingly rare. Thus we have 
warty excrescences, mucous polypi, fibroma, sarcoma, cys- 
toma, epithelioma, and carcinoma in this region. Warty 
excrescences and mucous polypi may be snipped off without 
much ceremony ; and even malignant growths are worth 
while removing for the sake of the interval of comfort, but 
the latter are pretty sure to return. Growths of all kinds are 
occasionally found in different parts of the urethra up to the 
neck of the bladder, but they are most frequently located near 
the meatus urinarius. 

Caruncles are usually of small size (from a pea to a straw- 
berry) and red color, situated at or near the meatus. Some- 
times these growths are pedunculated, but more frequently 
sessile. They consist of enlarged capillaries -surrounded by 



192 DISEASES OF WOMEN. 

condensed cellular tissue, and covered with mucous mem- 
brane. Caruncles are exquisitely sensitive, and give rise to 
much suffering. When they occupy the urethral tube the 
flow of urine is apt to be obstructed ; when placed at the 
meatus, friction generally results in bleeding and ulceration. 
Pain is not always limited to the meatus, but may radiate to 
the back, thighs, and other parts. The disease is sometimes 
mistaken for vaginismus. An ocular examination is impera- 
tive. These growths occur at all periods of life, but are more 
common after the menopause. They sometimes return, even 
after the most careful removal. 

Treatment. — Thorough excision is the only remedy. Be- 
fore operating, the general health should be attended to. 
More especially should the liver and bowels be set in order. 
Chronic constipation almost always complicates the affection. 
To relieve this, pills containing inspissated ox-gall, gr. ij., 
aloes, gr. j., sodium bicarbonate, gr. iss., and extract bella- 
donna, gr. J, will be found of service. Small doses of ergot 
may also be administered at bedtime with a view to reduce 
the congestion. 

The parts are so very sensitive that the patient must be 
fully etherized before operating. She is placed on a table 
on her left side (Sims' position), the tumor is firmly grasped 
with Mathieu's artery forceps, and excised with curved scis- 
sors. If the growth is large and vascular, it may be first 
painted with strong carbolic acid, the base transfixed by a 
short round needle armed with a double thread of carbolized 
silk, and tied above the needle in two parts, traction on the 
tumor being made with forceps by an assistant, and then ex- 
cised. The raw surface should be cauterized with Paquelin's 
thermo-cautery at a dull-red heat. Some surgeons prefer the 
actual cautery to destroy the growth, without excision. 

URETHRAL STRICTURE. 

This is not a very common affection in womien, being 
chiefly limited, to injuries occurring during parturition, and 



URETHRAL STRICTURE. 193 

secondary results of gonorrhoea. The stricture may be situ- 
ated at the meatus, at the junction of the urethra with the 
bladder, or at any intermediate point. When urethral stric- 
ture is a sequel of dystocia, it is generally caused by the for- 
mation of cicatricial bands in the anterior wall of the vagina, 
which press upon and contract the urethra. When gonor- 
rhoea attacks the female urethra (it is more commonly con- 
fined to the vagina) the disease may possibly be followed by 
a deposit of plastic lymph beneath the mucous membrane, as 
in the male. 

The ordinary symptoms of stricture are': more frequent calls 
to urinate, a smaller stream, greater force needed to empty 
the viscus, and sometimes pain. An ocular examination will 
reveal the presence of cicatricial bands, or narrowing of the 
meatus. Passing the surgeon's forefinger along the anterior 
vaginal wall may possibly detect thickening of the tube ; but 
the surest test is to slowly pass a slightly curved block-tin 
sound, previously warmed and oiled, until the stricture is 
reached. 

Treatment. — When dependent on the pressure of cicatricial 
bands, these must be snipped with scissors, and the urethra 
carefully dilated. If the stricture occurs at the meatus, it 
should be incised, and a dilator smeared with extract bella- 
donna inserted daily. When the bleeding stops, the raw sur- 
face may be covered with vaseline, and the application re- 
peated every time before passing urine till it heals. If the 
stricture is caused by gonorrhoea, it should be incised from 
within outward, and the patient taught to pass a suitable 
bougie, which she ought to do every day for at least a year. 
When the stricture is at the neck of the bladder, flat sup- 
positories containing belladonna and mercury oleate may be 
tried, followed by attempts at gradual dilatation ; this is the 
most intractable of all- the forms. Spasmodic constriction, 
caused by acrid urine or by a fissure at the neck of the blad- 
der, is sometimes mistaken for stricture. 
13 



194 DISEASES OF WOMEN. 



URETHRAL PROLAPSUS. 



The urethral mucous membrane may become prolapsed 
and appear as a tumor at the meatus. If recent, it should be 
returned ; but, in chronic cases, a portion may be removed 
with scissors, and one or two narrow lines marked with strong 
nitric acid on the superior wall, while the inferior wall is de- 
pressed with a small wooden speculum. 

Case XXVIII. — Miss S., twenty-eight years of age, a pa- 
tient of Dr. Elliott's, Woburn, Mass., was first seen by me 
February 28, 1 880. She had a distinct prolapsus of the ure- 
thral mucous membrane, complicated with two small carun- 
cles. She was tormented by calls to pass water every fifteen 
or twenty minutes, and latterly micturition was painful. Dr. 
Elliott dilated the urethra with four slippery-elm tents, a sil- 
ver catheter being left hi situ during the process. Next fore- 
noon she was etherized, the tents removed, and my forefinger 
readily passed into the bladder, but nothing else abnormal 
was detected. The caruncles were excised with scissors, and 
a circular strip of the redundant tissue removed. After the 
bleeding stopped — it was not profuse — a small wooden specu- 
lum (like a single blade of Sims' in miniature) was used to 
depress and protect the inferior wall, while a narrow whale- 
bone rod thinly covered with cotton and dipped in strong 
nitric acid was appHed to the superior wall nearly to the neck 
of the bladder. A soft rubber catheter was left in the ure- 
thra for three days after the operation. 

Six months later a slight return of the prolapse occurred, 
which was entirely relieved by excising a narrow longitudinal 
strip of mucous membrane. 

In addition to the diseases already described, we occasion- 
ally meet with certain other malformations and displacements 
of the bladder and urethra. Thus, we may have congenital 
extroversion of the bladder, with absence of the urethra and 



DISEASES OF BLADDER AND URETHRA. 195 

clitoris, a state of things which the celebrated surgeon, Erich- 
sen, pronounced incurable. Prof. Ayres, of Long Island Col- 
lege Hospital, operated on a case successfully in 1858. 

Again, instead of stricture, we may find the urethra un- 
naturally dilated throughout its whole length, or at some part 
of its course. When the dilatation is confined to the middle 
third, it is called iiretJirocele. This is best remedied by some 
sort of vaginal support (absorbent cotton soaked in a strong 
solution of tannin and a little dry tannin added), changed 
twice a day. 

During pregnancy more or less dislocation of the urethra 
occurs, materially altering the direction of the passage, so that 
the tube becomes nearly vertical, and in passing a catheter 
the instrument passes immediately behind the pubis. 



CHAPTER XIX. 
DISEASES OF THE RECTUM. 

HEMORRHOIDS OR PILES. 

Women are much more subject to this disease than men, 
although it is by no means a rare affection in males. But the 
more sedentary life of women, and especially the pelvic con- 
gestions so frequently present during gestation, predispose 
them to these attacks. The disease essentially consists in a 
relaxed and congested state of the veins and capillaries which 
ramify so abundantly in the lower part of the rectum, result- 
ing in swellings or bunches from the size of a pea to that of 
a Hamburgh grape, or even larger. 

Authors classify them as internal piles when found above 
the sphincter ani, and external piles when placed below that 
muscle. They have also been classed as blind and bleeding 
piles. The former are always external. Whatever their 
location, hemorrhoids present two distinct forms — the flat or 
varicose, and the globular or pediculated. Flat piles are 
generally internal. The blood in the globular kind fre- 
quently coagulates, forming a small, hard tumor. 

The skin and mucous membrane at the anus are liberally 
supplied with blood-vessels and nerves, and, when the vessels 
are much distended, the accompanying nerves are painfully 
put on the stretch. Young unmarried women are not as 
subject to piles as young men ; but whatever interferes with 
freedom of circulation in the portal system, irrespective of 
sex or age, predisposes to hemorrhoids. High living, seden- 



HEMORRHOIDS. 197 

tary habits, indulgence in malt liquors, free use of tobacco, 
and excessive venery, are apt to bring on the disease. The 
use of cheap newspapers to wipe the parts after defecation, 
and habitual want of cleanliness (daily washing is more 
needed here than anywhere) are also provocative of piles. 
Internal hemorrhoids, in women, most frequently make their 
appearance some time after delivery. 

Treatment. — Patients generally prefer to try some pallia- 
tive plan before submitting to an operation, although ''to 
this favor they must come at last." Some of these palliative 
measures do good service as preparatory treatment. The 
bowels must be gently unloaded (sulphur is the best laxa- 
tive), inflammation subdued by means of warm sitz-baths and 
injections, prefaced by the application of leeches if necessary ; 
blue-pill and ergot internally, and rest in bed. To keep the 
bowels open, use ox-gall pills, or a teaspoonful of the confec- 
tion of black pepper, sulphur, and senna in equal parts may 
be given every second morning. An enema of glycerine 
(3J. to the pint of water) every second day is an excellent 
laxative. But, in most chronic cases, removal with the 
ecraseur or ligature becomes necessary. 

Whether the piles be internal or external, the first step is 
to paralyze the sphincter ani by stretching, after the method 
of Professor Van Buren. The patient is thoroughly ether- 
ized, both thumbs inserted into the anus, and the sphincter 
stretched until it becomes paralyzed. Some think that the 
fibres of the muscle are ruptured during the process, and 
the sensation communicated to the operator resembles a tear, 
but the muscular fibres are not torn. Two fingers are then 
inserted into the vagina, and the rectal mucous membrane 
everted. In this w^ay we not only see every part of the dis- 
eased tissue, but can operate on it as easily as on external 
organs. If the base of the pile is broad, it is well to separate 
it somewhat from contiguous tissue by a partial dissection, 
and then apply the loop of the wire ecraseur to remove it. 
This process is repeated on each pile. When pendulous, no 



198 DISEASES OF WOMEN. 

dissection is needed. External piles, covered with a tough 
membrane resembling skin, may be safely snipped off with 
scissors. 

I have never found it necessary to remove hemorrhoidal 
growths with the ligature. This is the ordinary method, but 
it is both tedious and painful. The late Dr. J. Mason War- 
ren says: ''Retention of urine, requiring the use of the 
catheter for about three days — and I have once seen it last 
eight — is not an unfrequent occurrence." This accords with 
w^hat I have seen in hospital. The irritation set up by liga- 
tures is often extreme, and not free from danger. Septi- 
caemia is also much more apt to occur where the ligature is 
employed. Cases may possibly occur where ligation would 
be safer than the ecraseur ; but, in the great majority, the 
latter is preferable. During the last sixteen j^ears I have 
operated twenty-five times with the ecraseur — some of the 
tumors as large as a thumb — and have never been troubled 
with .either primary or secondary hemorrhage. The risk of 
bleeding is reduced to a minimum if we previously paralyze 
the sphincter ani ; and if it should occur, would reveal itself 
at once, and, the parts being accessible, it could be easily 
.arrested. 

ANAL FISSURE. 

Very few diseases so insignificant in appearance as this one 
rgive rise to so much intense suffering. The fissure is oftenest 
situated posteriorly in the median line, and can easily be de- 
tected by ocular inspection. Sometimes it is a sequel of 
ruptured perineum occurring during labor, or it may result 
.from the passage of hardened faeces. 

'ITreatnient. — Make sure of a free evacuation of the bowels 
'by means of a laxative the night before operating, and a co- 
pious warm-water enema the next morning. Etherize the 
patient thoroughly ; paralyze the sphincter ani in the way 
already detailed ; make a shallow incision with a scalpel 
through the mucous membrane of the fissure, and keep the 



RECTAL POLYPUS. I99 

parts perfectly clean until the ulcer heals. Opiates are seldom 
necessary. 

Case XXIX. — Mrs. M., a young married lady, of more 
than average intelligence, called along with her husband at 
my office, in December, 1876. Mr. M. narrated the symp- 
toms. He said that soon after her first and only confinement 
his wife dreaded to go to the water-closet on account of the 
intense pain attendant upon defecation. Her agony was so 
great that the sweat in great drops would roll down her face. 
No objection was made to an ocular examination, which re- 
vealed the presence of a small anal fissure near the coccyx. 
The operation was performed at the patient's house in Chel- 
sea next day, with immediate and permanent relief Care 
was taken not to allow drops of urine to come in contact 
with the rectum by freely smearing the parts with vaseline. 
Four years later there had been no return of the trouble. 

RECTAL POLYPUS. 

This is a rare affection, of which I have only seen two cases. 
Dr. Martin, of Roxbury, has also met with two. The late 
Dr. J. Mason Warren, in his admirable work, *' Surgical Ob- 
servations," gives details of three cases. The growth gener- 
ally consists of mucous, connective, and fibroid tissue, and is 
of a firmer consistence and larger size than ordinary hemor- 
rhoids. It is always pediculated, but in some cases the pedi- 
cle is as thick as a man's little finger. 

Treatment. — Removal by the wire ecraseur or scissors. In 
this, as in all operations on the rectum, the sphincter ani 
should be paralyzed before operating. The intestines should 
'also be emptied by laxatives and injections. The after-treat- 
ment consists of rest in bed and strict attention to cleanliness. 

Case XXX. — Mrs. D., of Salem, Mass., consulted me in 
March, 1876. Age, forty-four years ; has been married 



200 DISEASES OF WOMEN. 

eighteen years ; has one child fifteen years old ; n6 miscar- 
riage. First menstruated at thirteen years of age, without 
pain. Flow more profuse since birth of girl, and attended 
with some pain. Four years ago two polypi came from the 
vagina ; last July two more were discharged ; and one in 
January, 1876. The menstrual flow now lasts from thirteen 
to eighteen days ; commences with a slight show, which lasts 
a week, then a copious flow for another week, ending with a 
slight show for two or three days, as at the beginning. No 
nausea, slight headache, constipation, dysuria, which is ag- 
gravated during menstruation ; has to get up every night to 
pass water, often several times a night. Appetite pretty 
good. Consulted Dr. Kemble, of Salem, and Dr. Warner, of 
Boston, last summer. 

For convenience of treatment the patient came to board at 
my house. Two sponge-tents were inserted on succeeding 
days ; and on March 28th, with the assistance of Drs. Stevens 
and Wight, she was etherized, the second tent removed, and 
the uterus thoroughly explored with the forefinger. No 
tumor of any kind was found there ; but on passing my finger 
into the rectum to examine the posterior uterine wall, I was 
surprised to find a polypus as large as a pullet's egg. The 
sphincter ani was then paralyzed and the growth removed by 
means of a wire ecraseur. The hemorrhage was very slight. 
She returned home in seventeen days. 



RECTOCELE. 

This affection consists in the formation of a pouch in the 
posterior vaginal wall, or, in other words, the bulging of a 
pouch from the rectum into the vagina. This bag may even 
appear externally. The accident is apt to follow rupture of 
the perineum during labor. 

Treatment. — The bowels must be brought into good condi- 
tion and thoroughly cleared out before operating. The patient 
is fully etherized ; the rectocele pressed back with a sponge 



RECTOCELE. 201 

probang held by an assistant, and the surface denuded with 
scissors, forming a sort of half-moon figure. Deep stitches of 
carbolized silk are then passed behind the raw surface (keep- 
ing the left forefinger in the rectum as a guide) at a distance 
of half an inch apart, and tightened after the whole number 
have been inserted. But they must not be drawn very tight, 
allowance being made for the subsequent swelling of the tis- 
sues. The surface should be kept smeared with vaseline, to 
protect it from stray drops of urine ; and a flexible catheter 
used to empty the bladder at least once in eight hours. Or 
the parts may be washed with a small stream of carbolized 
tepid water every time that the catheter is withdrawn. 

It will be well to give the patient plain concentrated food, 
which leaves little residue in the bowels, but not to depend on 
opium or make any special effort to lock them up. After a 
few days, if she feels a desire to empty them, give an injec- 
tion of warm olive-oil, and instruct the nurse how to support 
the anus during defecation until several weeks have elapsed. 
The sutures should be removed at the end of twelve days.^ 

^ Dr. Pinkham, of Lynn, Mass. , gives the details of a case of rectocele success- 
fully operated on, in the Journal of the Gynaecological Society of Boston, vol, 
vii., p. 140. 



CHAPTER XX. 
GONORRHCEA. 

True gonorrhoea, both In men and women, is always com- 
municated by. contact during sexual intercourse. It occurs 
more frequently than any other form of venereal disease. 
But we may have a disease of the genitals in either sex so 
closely resembling gonorrhoea in its symptoms as to be readily 
mistaken for it, which has nothing whatever to do with an im- 
pure connection. Gonorrhoea is much less frequent in women 
than men. It may attack the vulva, the vagina, the urethra, 
or the uterus. Inflammation of one or both ovaries some- 
times follows as a sympathetic sequel. An attack of pelvic 
cellulitis has often been traced to gonorrhoeal infection. 

In youn^ girls, awkward pr too frequent intercourse, with- 
out specific contagion, is apt to excite vulvitis, accompanied 
with swelling of one labium or both labia, and inflammation 
of the vulvo-vaginal glands.' Occasionally, the duct of one 
of these glands becomes occluded, fluid collects, inflammation 
is set up, and an abscess is the result, while the adjoining tis- 
sues are not affected. 

Urethritis caused by gonorrhoeal poison is a somewhat rare 
affection ; but when it does occur it is exceedingly painful, 
and may spread to the bladder, producing cystitis. To ascer- 
tain whether the discharge comes from the urethra, wash out 
the vagina with carbolized warm water (l to 40), wipe the 
meatus with absorbent cotton, anoint your forefinger with 

^ Newly married women should be instructed hoAv to avoid these injuries by 
smearing the genitals with vaseline immediately before intercourse. 



GONORRHrEA. 203 

vaseline, introduce it into the vagina, and gently press the 
urethra from behind forward. If it is affected, eveji gentle 
pressure will cause pain, and muco-purulent matter will 
exude. 

Gonorrhoeal cervicitis is also rarely met with. When it 
does occur, the inflammation is generally restricted to the 
cervix, and does not pass beyond the internal os ; although 
it is not impossible that it may reach the fundus and even 
invade the Fallopian tubes. 

Vaginitis is by far the most common form. It commences 
with heat and tingling, a sense of fulness and discomfort in 
the parts. If seen early, the mucous membrane will be 
found unnaturally dry, followed by increased secretion within 
twenty-four hours, which varies in character according to the 
stage of the disease. At first it is transparent, then creamy 
or pus-like, and finally purulent. It may be of a greenish 
color, streaked with blood, with an offensive odor. The 
mucous membrane is tender and sensitive ; locomotion is 
painful; and if a small Neugebauer's speculum is entered, 
and the parts wiped with cotton, they will be found tumefied, 
bright red, and partially abraded. The clinical thermometer 
registers an increase of temperature, which may even be felt 
by the finger during an examination. The lower part of the 
vagina and the vulva are most frequently attacked ; occasion- 
ally the disease is chiefly confined to the upper part of the 
vagina. Ricord says that the anterior wall is more frequently 
affected than the posterior. The acute stage of gonorrhoeal 
vaginitis, if properly managed, seldom exceeds eight days ; 
but, on account of the numerous folds and recesses in the 
membrane affected, it is very likely to become chronic. 

In giving a name to inflammation of the genital mucous 
membrane, it is well to err on the safe side. As the venera- 
ble Dr. West says : " The microscope fails to furnish us with 
a means of distinguishing between gonorrhoeal and simple 
vaginitis, and no symptom or combination of symptoms is 
absolutely conclusive on the point." We must be guided 



204 DISEASES OF WOMEN. 

mainly by the history of the case and the moral status of the 
patient. But, while this is true, there can be little doubt that 
the virus of true gonorrhoea possesses some peculiarity not 
yet discovered, which is more likely to terminate in secondary 
lesions. Epididymitis in the male and ovaritis in the female, 
resulting from gonorrhoeal infection, are frequent causes of 
sterility. The spermatozoa are absent in the semen, or the 
ova do not reach maturity in the Graafian vesicles. The 
vulva is affected sooner or later in vaginitis, because the dis- 
charge irritates and inflames the external parts, sometimes 
even extending to the thighs and nates. 

Treatmejtt. — Absolute rest, sedative lotions, injections of 
hot water, and saline cathartics, constitute the best treatment. 
If severe vulvitis with swelled labia occur, hot sitz-baths, con- 
tinued for an hour at a time, will afford relief. Place a thin 
pledget of absorbent cotton or wool, soaked in glycerine and 
dusted over with morphia (gr. ij.), and lead iodide (gr. iv.), 
between the inflamed labia. The patient should lie on a 
lounge, with the pelvis elevated, for at least four days. One 
of the best sedative lotions is a decoction of poppy-heads 
to which one-fourth part dilute Goulard's lotion has been 
added. The external parts may be freely bathed with this 
lotion ; and, largely diluted with hot water, it should be used 
as an injection four times a day or oftener. The best ar- 
rangement for this purpose is the vaginal douche described 
at p. 40, and the same rules apply here. The hips must be 
higher than the shoulders, and not less than a gallon used at 
a time. Cold water is seldom safe or suitable. 

After the extreme severity of the inflammation has been 
subdued, astringent or tonic injections will be in order. Tan- 
nin, matico, zinc acetate, or zinc sulphate, may be used. The 
strength of the solution should be proportioned to the sensi- 
tiveness of the patient. One fluid ounce is as much as can 
be retained. The diet should be mostly farinaceous, and fer- 
mented liquors must be totally avoided. 



GONORRHUb:A. 205 

GONORRHGEAL RHEUMATISM 
is a rare affection in women. I have seen only one case, and 
that was doubtful. It is distinguished from ordinary rheu- 
matism by the mildness of the constitutional symptoms. In 
several respects it is said to resemble gout more than rheu- 
matism. It is sometimes complicated with ophthalmia, which 
may precede or succeed the rheumatic attack. Once affected, 
a new " clap " is apt to be followed by the same sequelae. 

Treatment. — Begin with a mild purgative. When the pain 
is severe, apply leeches to the joint, repeating them next day 
if necessary. But our main reliance is to be placed on small 
blisters frequently applied. A cauterizing iron held in boil- 
ing water for a few minutes answers the purpose admirably ; 
or we may apply the liquid cantharidal vesicant on a surface 
as small as a nickel, painting two or three coats at a time on 
at least two places every day until the effusion is absorbed. 
Lugol's solution of iodine may be substituted for the cantha- 
rides. After the acute symptoms have subsided, apply a 
Martin's rubber bandage to the affected joint. 

The ophthalmia, if it occurs, must be treated on general 
principles, namely, leeches to the temples, weak solution of 
atropia to the conjunctiva, appropriate diet, and a darkened 
room for the patient. 



CHAPTER XXI. 

SYPHILIS. 

« 

CHANCROID. 

Chancroid and chancre are two distinct diseases. The 
former is essentially a local affection ; the latter is a blood 
disease, marked at first by an insignificant-looking sore, but 
invariably followed by constitutional symptoms, such as 
eruptions. Chancre is syphilis in its primary form. 

In hospital practice chancroid ranks next to gonorrhoea in 
frequency. As compared with chancre, it occurs at least twice 
as often ; for this reason, that one attack confers no immu- 
nity from subsequent infection, whereas chancre does. 
Chancroid is most frequently found on the genitals, and is 
generally communicated during coitus. The ulcer is inflamed 
and painful, with a tendency to spread, and it generates a 
creamy pus which is infectious. The pus-globules alone pos- 
sess the power to produce the disease by inoculation ; the 
serum separated by filtration being innocuous. Hence, the 
reason why chancroid is necessarily a local disease, because 
the pus-globules cannot pass beyond the nearest lymphatic 
gland, where a bubo may be formed ; but the circulating 
blood is not contaminated. 

Chancroids are most frequently seen at the fourchette, on 
the inside of the labia, and lower part of the vagina. On ac- 
count of the follicles becoming infected, they often appear 
like small boils or abscesses. Sometimes they look like 
fissures, especially in prostitutes. A chancroid is rarely, if 
ever, found on the head or face, so that a venereal sore in 



CHANCROID. 207 

that locality may be set down as a chancre. When a chan- 
croid forms in the urethra it is apt to be followed by a 
stricture. 

In cases of doubt, inoculation of the pus on the chest is 
the surest aid to correct diagnosis. The chancroid thus 
created should be immediately burned out with nitric acid or 
other potent cautery. 

Treatine7tt. — If seen early, a chancroid should be freely 
cauterized. Pure nitric acid, applied with a smooth glass 
rod, is the best escharotic. Ricord recommends a paste made 
with finely pulverized charcoal and pure sulphuric acid, put 
on with an ivory spatula. Some employ the actual cautery 
at a red heat. Either of these methods, by destroying the 
virus, converts the chancroid into a simple ulcer, to be treated 
on general principles. If a strong acid is used, the part 
touched should be freely dusted with sodium bicarbonate, to 
neutralize superfluous acid. 

If the patient will not submit to cauterization, the next best 
treatment is to sprmkle the ulcer with iodoform, and cover it 
with absorbent cotton. Afterward a dry dressing of iodized 
cotton, changed twice or thrice a day, is preferable to wet 
applications. Ointments of all kinds, and especially mercu- 
rial ointments, must be sedulously avoided. 

The diet should be plain, but nourishing, abstaining from 
indigestible articles and stimulants. No internal medicine is 
specially indicated. Mercury in any form is hurtful, unless 
we have what is called a *' mixed sore," that is, a true syph- 
ilitic sore as well as a chancroid. Of course, if the bowels 
are constipated they must be attended to; and if the general 
health has become impaired, tonics and change of air will be 
in order. The sore heals quickly or slowly as the general 
health improves or suffers. When chancroids spread like a 
serpent (serpiginous),- or take on a phagedenic character, 
they are very difficult to cure. In all cases, but especially 
severe ones, rest is an important item in the treatment. 



208 DISEASES OF WOMEN. 



CHANCRE. 



No disease has given rise to more controversy than syphiHs. 
The celebrated John Hunter actually believed that gonorrhoea 
and syphilis were identical. Many medical books published 
within fifty years contain the most astonishing jumble of non- 
sense about venereal diseases. Robert Druitt, in his " Sur- 
geon's Vade Mecum " (1841), evidently confounds chancroids 
with chancres. He says : " If a chancre last for a few days only, 
there will be no fear of secondary symptoms." ^ It is only during 
the present generation that clear ideas have been formed as 
to the essential distinctions between gonorrhoea, chancroid, 
and chancre ; while many points relating to hereditary syphi- 
lis still remain undecided. At present few surgeons deny that 
a simple chancroid is more than a local affection, and is never 
followed by constitutional syphilis ; and nobody believes in 
the identity of the gonorrhoeal and syphilitic poisons. 

True syphilis has been compared to variola or scarlatina. 
Like them it has a period of incubation, and one attack gen- 
erally shields the individual during her lifetime. In some 
persons the effect produced on the system dies out, and they 
are liable to be infected a second time on exposure. The pe- 
riod of primary incubation lasts from two to six weeks, gener- 
ally not more than four weeks. 

The ulcer, in most cases, is quite superficial — a simple ero- 
sion — and therefore likely to be overlooked in women. Its 
most frequent seat is one of the labia majora or minora. But 
any part of the mucous membrane may be affected. Chancres 
have been found in the urethra, the anus, high up in the 
vagina, and even on the cervix uteri. The nipple may be 
affected from suckling a syphilitic infant. Or the disease 
may be communicated to the lip during the act of kissing. 
Generally the base of the sore is more or less indurated, like 

^ Hebra and some other German writers use the term " chancre " when speak- 
ing of what we call chancroid. What we call chancre they designate as " primary 
syphilis." 



SYPHILIS. 209 

parchment; more rarely it resembles a split pea. There is 
no inflammation or soreness. In this respect it differs from 
a chancroid, which is always painful. After a variable length 
of time induration disappears. The secretion is mainly 
serum, unless the sore is irritated by caustics or dirt, when 
pus will be formed. If the superficial ulcer is allowed to run 
its natural course, no cicatrix will remain after it heals. 
Chancres are single, not multiple, unless the virus is commu- 
nicated to several abraded surfaces simultaneously. For, 
although the virus of chancre is contagious when applied 
to a person who has never had syphilis, it is not auto- 
inoculable. 

One of the most characteristic early symptoms is the indu- 
ration of the neighboring ganglia, sometimes called syphilitic 
bubo. As a chancre occurs most frequently on the genitals, 
the glands in the groin are commonly affected ; the indura- 
tion takes place within a few days after the ulcer appears, 
rarely later than a week. If the chancre is situated on the 
lip, the submaxillary glands become indurated. There are 
no signs of inflammation present ; and this symptom is apt 
to be overlooked, especially in fat patients. The induration 
is likely to last for several weeks, it may be for many months. 
A syphilitic bubo rarely suppurates ; the exceptions occur- 
ring in scrofulous or broken-down women, and not very often 
even in them. A chancroidal bubo often ends in suppura- 
tion ; so that the formation of pus in a bubo is corroborative 
evidence that the original disease was not syphilitic. 

Treatment. — As a chancre is the primary lesion of a consti- 
tutional disease, it would be folly to attempt abortive treat- 
ment. The virus gets beyond our reach as soon as it enters 
the blood, that is, instantaneously. If the local sore is super- 
ficial, simple dressing with iodized cotton, or dusting the sur- 
face with iodoform, is all that is needed. Iodide of starch or 
carbolated magnesia may be used instead. 

The general treatment is comprised in administering minute 
doses of mercury biniodide (y-^Q- gr. after breakfast and supper) 
14 



2IO DISEASES OF WOMEN. 

till the ulcer heals and the indurated glands return to their 
normal state, followed by potassium iodide, and afterward 
iron phosphate. The late Dr. Bumstead strongly recom- 
mended waiting till secondary symptoms appear before be- 
ginning to give mercury. In any case, care must be taken 
not to salivate the patient. It is scarcely necessary to add 
that the general health should be sedulously attended to. 



CONSTITUTIONAL SYPHILIS. 

The general symptoms which invariably follow a chancre 
have been called secondary and tertiary syphilis. These may 
be delayed by appropriate medication ; but they always come 
sooner or later. The presence of the primary sore, and even 
the induration of the neighboring ganglia, are often over- 
looked in women. A superficial erosion of small extent, 
painless, and discharging only a little serum, may not attract 
the patient's attention. In most women the inguinal glands 
are so embedded in fat that a slight enlargement, not attended 
with pain or redness, is. also likely to escape her notice. But 
a roseolar or papular eruption is sure to send her for advice 
to a physician. In many cases we are unable to ferret out 
the original lesion in women, but there can be no reasonable 
doubt of its previous existence. 

Secondary Syphilis. — After a chancre has fully formed, 
and generally after it has healed, a second period of incuba- 
tion elapses before secondary symptoms appear. This period 
may be as short as three weeks, is seldom longer than three 
months, and scarcely ever exceeds six months. Secondary 
symptoms are prefaced by general lassitude and slow fever, 
followed by sore throat, skin eruptions, onychia, alopecia, 
mucous patches, enlargement of the post-cervical and epi- 
trochlear glands, and iritis. Some of these symptoms may 
appear before the original ulcer has healed ; and they are 
likely to occur at short intervals for several months, thus 
simulating a series of relapses. 



SYPHILIS. 211 

Before any eruption, a sort of syphilitic fever supervenes. 
It is attended with shght increase of temperature, occa- 
sional headache, depression of spirits, loss of appetite, furred 
tongue, wandering pains in the larger joints, and tenderness 
on pressure over the upper and lower third of the sternum. 
These symptoms seem to depend on the anaemia caused by 
the general disease. It has been found that the number of 
red corpuscles present in the blood is reduced from one- 
seventh to one-half in patients so affected. 

Syphilitic affections of the skin so closely resemble ordinary 
skin diseases, that even an expert is sometimes at fault. 
Fournier has called attention to the occurrence of analgesia 
in syphilitic women, sometimes associated with a deficient 
sense of touch and temperature. The back of the hand is 
most frequently affected ; although, in some cases, nearly 
the whole cutaneous surface loses its sensibility. The most 
common skin affections are roseola, papules, vesicles, and 
squamae ; but the variety is almost infinite, and generally 
several kinds appear together. They are very persistent, 
but not usually attended with itching. 

The most common form is roseola (syphilitic erythema), 
which consists of rose-colored spots, obliterated on pressure, 
and commonly confined to those parts of the body covered 
with clothing. After a time, the spots have a dusky red 
color, like newly sliced raw ham. Papules are often scattered 
all over the body, but are most abundant on the abdomen 
and forehead. Vesicular eruptions are comparatively rare, 
occurring oftenest on the back and face. They soon become 
purulent and form scales. Scaly eruptions are principally 
met with on the scalp and eyebrows, and are complicated 
with alopecia. Delicate, white-skinned, lymphatic women 
are subject to a coffee-colored pigmentary syphilide, which, 
according to Dr. Keyes, shows itself between the fourth and 
twelfth month after ihe primary affection. 

Temporary alopecia is a common secondary symptom. 
After a few weeks or months, the hair grows again ; but there 



212 DISEASES OF WOMEN. 

are cases, mostly tertiary, in which the hair-bulbs die, and 
the loss is permanent. 

Mucous patches are found on the vulva, anus, mouth, 
tonsils, and elsewhere. They are generally raised a little 
above the surface, although they are sometimes on a level, 
and may even be depressed. They are of a pinkish hue or a 
dirty white, and covered with an offensive secretion which is 
undoubtedly contagious. Condylomata is another form of 
the same affection, commencing on the skin surrounding 
mucous cavities, as at the anus and vulva. They look like flat 
warts. Mucous patches are apt to cause severe pruritus, and 
are difficult to cure. Onychia begins at the root of the nail. 

The post-cervical glands and those behind the ear are almost 
always enlarged during a secondary attack. The epitrochlear 
gland (at the bend of the elbow% immediately above the inter- 
nal condyle) is also sometimes affected. The back of the 
neck and inside of the elbow are therefore good places to 
examine when doubtful about suspicious-looking skin erup- 
tions. 

Iritis is a common sequel in secondary syphilis, and there is 
no complication which demands such prompt and careful treat- 
ment. We cannot always be sure that iritis has a syphilitic 
origin ; although the late Professor Graefe calculated that 
'' about sixty per cent, of all cases of iritis occur in persons 
affected with syphilis." In severe cases an oculist should be 
early consulted. 

Treatment. — According to Bassareau, the early administra- 
tion of mercury has a tendency to retard the appearance of 
eruptions. As a general rule, secondary symptoms appear 
earlier in women than in men. It is seldom that we are called 
on to treat the initiatory fever. Mercury aggravates this fever, 
>which is best treated with small doses of potassium iodide, 
along with Fowler's solution or dialyzed iron. After the 
fever has subsided, mercury in some form is our sheet-anchor. 
Mercury is as much a specific in syphilis as quinine is in 
malaria or sulphur in scabies. But, like every potent remedy. 



SYPHILIS. 213 

it must be given judiciously. Hygienic measures should 
always precede or accompany a mercurial course. Sulphate 
of cinchonidia, fl. extract of coca, infusion of gentian, or dia- 
lyzed iron, may be employed by turns when the patient is 
debilitated ; or one of these tonics can be used in conjunction 
with a mercurial. The following is a favorite prescription : 

^ . Hydrarg. biniod gi*- ij- 

Potassium iod gr. iv. 

Sp. vini gallici fl. 3 j. 

Syr. zingib fl. 3 iij. 

Water | iss. 

M. Dose, 20 drops in a teacupful of water after breakfast 
and supper. 

Even this small quantity will salivate some patients ; we must 
therefore keep a good lookout to guard against salivation. 
Inunction or fumigation are preferable with delicate patients. 
Rub in the oleate of mercury on the inside of the thigh (half 
a drachm, five p. c. strength) every night ; or, for the sake 
of economy, an ointment made by triturating two parts of 
vaseline with one of metallic mercury. This preparation may 
be gently rubbed over enlarged glands. Iritis requires the 
free use of atropia solution (gr. iv. to the ounce) dropped 
into the eye till full dilatation of the pupil takes place, and 
repeated at intervals till the inflamm.ation subsides. Leeches 
to the temples are often of service. 

TERTIARY SYPHILIS. 

As a general rule, not less than two years elapse after 
infection before tertiary symptoms make their appearance ; 
and sometimes the interval extends to forty years or longer. 
They are much more formidable than secondary symptoms, 
on account of the insidious nature of their approach, and the 
sudden destruction of important organs, such as the palate. 



214 DISEASES OF WOMEN. 

All deep-seated and long-delayed syphilitic lesions come 
under the tertiary head ; but their essential feature is the 
deposit of gummy tumors in the skin or subcutaneous cellular 
tissue, bones, brain, and viscera, which are prone to break 
down and result in permanent loss of substance. 

Gummy tumors under the skin are at first freely movable. 
They are slow of growth, and for a long time painless ; but 
latterly inflame, become adherent, soften at the centre, and 
ulcerate. Nodes principally attack the tibia, ulna, and other 
subcutaneous bones. A diagnostic peculiarity of nodes is the 
nocturnal occurrence of the pain, which deprives the patient 
of sleep, and seems to be aggravated by, if not dependent 
on, the increased warmth of the body while in bed. The 
mammary glands are occasionally the seat of gummy tumors, 
which have been mistaken for cancer. Both breasts are com- 
monly affected. More rarely the disease shows itself in these 
glands as a diffuse parenchymatous inflammation. 

Treatment. — Iodine in some form, and most frequently 
potassium iodide (combined, in certain cases, with minute 
doses of mercury), constitutes our chief remedy. Two points 
should be attended to in administering iodine, namely, the 
dose must be large enough, and given in plenty of water. 
We can begin with potassium iodide, gr. v., four times a day, 
increasing the dose gradually up to two or three drachms 
during the twenty-four hours, if necessary. After decided 
improvement is manifest, the dose should be gradually re- 
duced, but not entirely left oft" for twelve months at least. 
Sodium iodide may be substituted for the potassium salt 
with advantage in certain cases. Dr. Andrew Buchanan, of 
Glasgow, recommends the iodide of starch as less irritating 
to the stomach and more economical.' Small doses of qui- 

^ Iodide of starch may be prepared in a glass mortar by triturating twenty-four 
grains of iodine with a little water, adding gradually an ounce of very finely pow- 
dered wheat-starch, and continuing the trituration until the compound assumes a 
uniform blue color. Gentle heating in a porcelain vessel over a sand-bath renders 
it more soluble. 



SYPHILIS. 215 

nine or coca, continued for months, generally prove benefi- 
cial. 

Syphilitic cachexia is most marked during the tertiary 
affection. It is often attended with amenorrhoea. Besides a 
general lowering of all the vital processes, it is frequently 
accompanied by great depression of spirits — syphilophobia — 
not seldom ending in suicide. To combat these general 
symptoms requires not only the highest skill in the physician, 
but also the greatest amount of patience and painstaking. 
Change of climate, nutritious diet, strict attention to cleanli- 
ness, and pure air while indoors, are potent adjuvants. I 
have no doubt that many of the benefits credited to a resi- 
dence near mineral springs are due more to the above agencies 
than to any special virtue in the water, although copious 
libations of any pure spring water is a depurant not to be 
despised. 

HEREDITARY SYPHILIS. 

A (qw facts relating to this question have been settled, but 
many points still remain undecided. There can be no ques- 
tion that men are more frequently to blame than women ; 
that is to say, directly or indirectly, men are commonly the 
door by which syphilis enters the family. Strictly speaking, 
the term hereditary (or congenital) only applies to the dis- 
ease communicated to the foetus while in titero ; although it 
sometimes happens that the infant is infected while passing 
through the vagina ; and it may be infected by suckHng a 
nurse with a chancre or mucous patch on her nipple. On 
the other hand, a syphilitic infant with mucous patches on its 
mouth may communicate the disease to a healthy wet-nurse, 
more especially if her nipple is abraded or fissured. It is a 
somewhat remarkable confirmation of the constitutional char- 
acter of syphilis that no instance has ever been noticed of the 
disease being communicated in this way to the child's own 
mother, her system having been already affected and conse- 
quently protected. 



2l6 DISEASES OF WOMEN. 

Abortion at an early period is the most frequent terminus 
of pregnancy in a tainted woman. Many women continue to 
abort year after year, until the disease is cured or wears out, 
and then they may bear healthy children. 

Syphilitic children seldom show any signs of the disease at 
birth. Skin eruptions or mucous patches almost always 
appear within two months, and very rarely after four months ; 
so that when a child remains healthy after that period the 
probabilities are strongly in its favor. It should, however, 
be borne in mind that the original taint may apparently be 
cured, and yet reappear in the tertiary form years later. 

The longer the time that elapses after infection of the father 
or mother, the less the chances of communicating syphilis to 
the foetus ; but it must be confessed that so long as the poison 
affects the system of either parent it may be communicated 
through them to the offspring. Physicians are often con- 
sulted by men, and sometimes by women, as to the propriety 
of marriage after a syphilitic attack. It is self-evident that 
no conscientious man or woman should ever form a matrimo- 
nial alliance while laboring under any obvious syphilitic taint. 
The question is narrowed down to the period which should 
be allowed to elapse after all such symptoms have disap- 
peared, and an interval of two years seems as short a time as 
is compatible with safety. 

The symptoms which make their appearance in infants, 
generally within a few weeks after birth, are — marasmus, loss 
of appetite, a peculiar shrinking and discoloration of the skin 
which gives an old-mannish look to the child, skin eruptions, 
mucous patches, ** snuffles," and purulent ophthalmia. If the 
child grows up it is always weakly and ailing. Mr. Hutchin- 
son, of London, calls attention to the fact that in syphilitic 
children the central permanent incisor teeth of the upper jaw 
are dwarfed and notched, and all the teeth are stunted. Cor- 
neitis is frequently associated with syphilitic teeth. 

Treatment. — The same remedies are employed as in adults 
infected in the ordinary way. Inunction of mild mercurials 



SYPHILIS. 217 

or fumigations, potassium iodide, largely diluted with water, 
and disinfectant warm baths, sometimes work wonders in 
such cases. Hygienic remedies are equally important. 
Among these may be reckoned quinine, iron, coca, and cod- 
liver oil. The strictest attention should be paid to keeping 
the infant dry and clean ; and no remedy will avail much 
without the potent influences of fresh air and sunshine. 

If the mother aborts, and syphilis is suspected, the reme- 
dies already mentioned for secondary symptoms may be ad- 
ministered even during pregnancy. 



CHAPTER XXII. 

CANCER. 

The main point placed beyond dispute about cancer is, 
that it is a malignant disease, which if not soon removed 
ends inevitably in death. There are three varieties, namely, 
scirrhus, encephaloid, and epithelioma. In all these forms 
the disease essentially consists in a deposit of new growths — 
principally cells, which finally usurp the place of healthy 
tissue. After a time this abnormal cell-growth begins to 
decay, forming an excavated ulcer (whence the sanious 
bloody discharge), the disease spreads in all directions, the 
lymphatic glands are involved, and from a merely local affec- 
tion it becomes a constitutional one. At this stage the pecu- 
liar cancerous cachexia appears ; the patient has a waxy, 
straw color, loses appetite, becomes listless and enervated, 
and finally succumbs. 

The organs principally affected in women are two, the 
uteru'S and mammae. The ovaries and vagina are also some- 
times attacked, though not so frequently. 

Young women are not as subject to cancer as the middle- 
aged ; but when they are attacked the disease runs a more 
rapid course. The encephaloid form occurs oftener in young 
persons, and scirrhus in the aged. According to Dr. Emmet, 
epithelioma is almost entirely confined to women who have 
borne children, or who at least have been impregnated. He 
believes that laceration of the cervix is a common exciting 
cause. Genuine scirrhus rarely attacks the womb. 

Soon after its commencement, uterine cancer is character- 
ized by unnatural fixation. As Waldeyer says, the mucous 



CANCER. 219 

membrane of the cervix is fastened by epithelial plugs to the 
subjacent tissue as if by little nails. The cellular tissue in the 
broad ligaments and elsewhere is infiltrated, and the uterus 
becomes immovable. 

Cancer is remarkable for its insidious approaches. Often 
the patient is entirely ignorant that she is affected until the 
disease has advanced so far that ulceration has commenced, 
the vagina is involved, and the uterus is firmly fixed. In 
some cases premonitory symptoms are noticed, such as dart- 
ing pains in the pelvis, loss of appetite, restlessness, and 
general discomfort. 

Pain is a common symptom, especially when the body of 
the uterus is first affected ; but pain is seldom present during 
the early stages, and in some cases is absent to the end. A 
w^atery discharge, with a peculiar offensive odor, is often the 
first symptom which attracts attention. After the meno- 
pause it sometimes betrays its presence by a copious dis- 
charge of blood and serum, inducing the notion that men- 
struation has come back again. Much stress has been laid 
on the revelations of the microscope in determining the 
existence or absence of cancer, and there can be no doubt 
that a good deal may be learned from a careful microscopic 
examination ; but the general practitioner is more likely to 
arrive at a correct conclusion by paying attention to symp- 
toms and trusting to the tactus eruditus. 



CANCER OF THE UTERUS. 

The encephaloid is the most common of all the forms. The 
disease commences at the cervix ; or, at all events, it is there 
the physician generally finds it. Professor Thomas has only 
seen two cases of soft uterine cancer which evidently began 
in the body or fundus -without involving the cervix. Sir 
James Simpson gives tlie details of several cases characterized 
by a watery discharge, which could be arrested temporarily 
by plugging the os uteri. It is rare indeed to see cancer of 



220 DISEASES OF WOMEN. 

the cervix before it has become ulcerated, because patients 
are seldom aware that anything serious is the matter with 
them during the early stages ; but after ulceration has set in 
the educated finger can easily detect the disease. The parts 
are friable, bleed easily, have a fetid odor, and the upper 
part of the vagina is infiltrated and leathery. For these 
reasons it is better not to use a speculum in making the 
examination, to avoid the risk of tearing the tissues. The 
odor, in some cases, is absent. 

Treatment. — Amputate slowly with the galvanic cautery, 
scoop out the diseased tissue thoroughly with Simon's spoon, 
apply bromine dissolved in alcohol (i to 5) to the raw sur- 
face ; and wash out the vagina twice a day with a solution of 
bromine, made by dissolving it in a saturated watery solution 
of potassium bromide. After one week, a strong solution of 
potassium permanganate may be substituted for the bromide. 
Under this active treatment, the patient will probably be re- 
stored to health for a time ; but too often the disease returns, 
either in the uterus or in some other organ. The diet should 
be composed largely of milk, eggs, and subacid fruits. 

If the disease returns and cannot be eradicated, she must 
be made as comfortable as possible by the free use of opiates 
in small doses frequently repeated. Hypodermic injections 
of morphia acetate give most relief. Suppositories contain- 
ing powdered opium, enemata of " black drop," and brandy 
given by the mouth, may also be needed. Hot douches of 
potassium permanganate, or hydrate chloral, or sulphurous 
acid in cold water, help to keep the vagina clean, besides 
allaying pain. I have tried a stream of carbonic acid gas in 
two cases, but it soon loses its soothing effect, and is liable to 
be followed by alarming symptoms. 

Case XXXI. —Mrs. W., Greenwood, Mass., aged fifty 
years ; American ; well educated and intelligent ; mother of 
two children, consulted me August 16, 1865. Found a hard 
tumor protruding from the os uteri, about the size of a large 



I 



CANCER. 221 

walnut, firmly attached to the inner surface of the cervix, 
which bled profusely after inserting a bivalve speculum. She 
had been subject to attacks of bleeding at intervals since May 
last. Applied Monsel's styptic and plugged the vagina. 

August i8th. — Met Dr. H. R. Storer in consultation. He 
recommended free incision of the cervix on both sides, which 
was done, with but little hemorrhage. The result appeared 
to be a great success. She took quinine and iron mixture 
internally ; the bleeding was arrested for several months. 

November 4th. — The hemorrhage returned ; but was easily 
controlled by cold-water injections, with aromatic sulphuric 
and gallic acids internally. 

November 9th. — Dr. Storer came out again. On examina- 
tion we found that the tumor had increased in size, was very 
soft and friable, and was evidently cancerous. Dr. Storer 
removed it principally with his fingers, and afterward applied 
the actual cautery. 

December 2d. — Anasarca set in. Much fetid watery dis- 
charge from the vagina. Mental depression. 

April 2, 1866. — At this date my attendance ceased, and the 
case was transferred to an irregular practitioner, who prom- 
ised to cure her in a month, and tried to do so by smart pur- 
gation. She died May 5, 1866. No autopsy. 

EPITHELIOMA OF THE CERVIX. 

This form was described by Dr. John Clark as early as 
1809, under the name of "cauliflower excrescence." It has 
also been called cancroid and papilloma. It consists in great 
enlargement of the papillae, with thickening of the mucous 
membrane. These club-shaped projections have cells depos- 
ited among their meshes, and the whole growth is succulent, 
so that when the abnormal tissue breaks down, a watery, 
bloody discharge with a bad odor is the first symptom which 
directs the patient's attention to her trouble. Some micro- 
scopists assert that the cells are not really cancerous. 



222 DISEASES OF WOMEN. 

Treatment. — Substantially the same as that already detailed 
for the encephaloid form. It is less liable to return if thor- 
oughly eradicated. Strict attention must be paid to diet and 
hygienic surroundings. Opiates and stimulants are needed 
as palliatives in hopeless cases. 

Uterine cancer is sometimes complicated with pregnancy. 
In such a case, it would be better to incise the cervix soon 
after the second stage of labor commences than wait till it is 
lacerated by the child's head. When the disease involves the 
vagina, or passes higher than the os internum, the best plan 
would be to perform the Caesarean operation. 



CANCER OF THE OVARY. 

A primary carcinomatous affection of the ovary in any form 
is very rare ; but we often meet with it as a secondary dis- 
ease. Dr. Charles Clay, of Manchester, " found but six 
instances of undoubted carcinoma [of the ovary] in five 
thousand cases diagnosticated by him." The growth seldom 
exceeds the size of the fist ; but the late Dr. Peaslee mentions 
one he saw in consultation "in which the tumor weighed 
nineteen pounds." The diagnosis is beset with difficulties, 
and no curative treatment is available short of extirpation. 



CANCER OF THE VAGINA. 

As a primary affection this form is rare ; but it is quite 
common during the later stages of uterine cancer. The lips 
of the womb become adherent to the vaginal walls, leaving a 
somewhat thickened ring to mark the spot where the cervix 
commenced ; but even this distinction after a time disappears, 
and the altered vagina forms a continuous tube with the organ 
first affected. In most cases the vagina seems to be short- 
ened and the uterus enlarged. The anterior vaginal wall 
soon becomes infiltrated, and finally eats into the bladder. 



CANCER. 223 

resulting in an incurable fistula ; or the posterior wall is simi- 
larly affected, communicating with the rectum. 

The following (personal) case is interesting on account of 
its occurring primarily. 

Case XXXIL— Mrs. D. T., Woburn, Mass., aged forty-six 
years. First menstruated at eleven years old. Never had 
any pain at her monthly periods. Before marriage at one 
time went a whole year without menstruating. Has borne 
seven children ; first two were still-born ; five now alive ; old- 
est seventeen years, youngest four years old. 

Applied to me August 23, 1876. About a year ago patient 
discovered something pressing in the pelvic region. Six 
months ago, a watery flow, tinged with blood, appeared. 
No pain at any time. Is troubled with frequent calls to pass 
water through the day, and requires to urinate four or five 
tim.es every night. Occasionally has fever turns with head- 
ache. Appetite good till one week ago. Bowels regular. 
Sleeps pretty well at night. Has had a " nervous " cough all 
summer. 

Next day I made a vaginal examination at the patient's 
residence. Found a large encephaloid growth in the vagina, 
commencing fully one inch below the uterine neck, which 
was unaffected. The tumor projected into the rectum at its 
lower border. Dr. Winthrop F. Stevens administered ether, 
and I removed the growth by enucleation, mainly with my 
fingers. There was very little hemorrhage. A recto-vaginal 
fistula remained after the operation ; but it is remarkable 
that no faeces ever passed into the vagina during the remain- 
der of her life, although the opening allowed a man's thumb 
to pass through easily. 

At first the result proved satisfactory. The patient's pulse, 
which had previously averaged 120 beats per minute, came 
down to 80 ; her appetite returned ; the calls to urinate were 
not as frequent during the daytime and did not disturb her 
at all during the night. Early in October, however, it be- 



224 DISEASES OF WOMEN. 

came evident that the disease had taken a fresh start. Dr. 
Bixby, of Boston, saw her in consultation, and counselled 
non-interference. In November, some of her relatives were 
anxious that a further attempt should be made to save her, 
and Dr. Ephraim Cutter was consulted. He tried to destroy 
the growth with the galvano-cautery, but with no appreci- 
able benefit. She died January I, 1877. No autopsy was 
performed. 

CANCER OF THE BREAST. 

The mammary glands rank next to the uterus in the fre- 
quency with which they are attacked with cancer. The 
scirrhous form is more common. In many cases the axil- 
lary glands become affected soon after the disease betrays 
itself It is usually confined to one breast at first, but the 
other may subsequently become involved. Dr. Walshe, of 
London, describes two forms — the atrophoiis and hyper tro- 
phous. In the former, all the tissues contract, become matted 
together, forming a single layer of almost stony hardness, 
which cuts crispy, like an unripe pear, and exudes a reddish 
fluid under pressure. In the latter, the affected breast in- 
creases in size ; it may be even double that of the sound one. 
When cancer occurs in the nodular form, it is generally situ- 
ated near the axillary border of the breast, feels smooth, 
round, and movable, and is free from pain. But after a vari- 
able interval of time, the tumor becomes knotty, uneven, 
more or less fixed, and painful when handled. Finally, we 
find the skin adherent, and the nipple retracted or sunken. 
In the infiltrated variety the whole gland seems to be affected 
from the first; there is no circumscribed tumor. The skin 
has a dull, white appearance, afterward shining and stretched, 
and at last becomes of a dusky, livid color, mottled with en- 
larged veins. Besides the nipple, small areas of skin become 
retracted, giving the gland a peculiar dimpled appearance. 
Sometimes this infiltrated state of the skin spreads to the 



CANCER. 225 

chest and arm, rendering motion on that side difficult or 
impossible. Before operating, a careful examination of the 
rest of the body should be made, to ascertain whether other 
organs are involved, and to what extent the disease has pro- 
gressed in them. If other organs are implicated, an operation 
could only be palliative. 

Treatment, — Early removal of the entire gland, before the 
neighboring parts become infiltrated, is the only safe remedy. 
Much diversity of opinion prevails among surgeons as to the 
advisability of operating after the axillary glands have be- 
come affected, and more especially after the skin is adherent. 
Some have even tried to prove by statistics that surgical 
interference shortens the patient's life. But the cases must 
be rare indeed where removal of a putrid mass injures the 
sufferer. In one case, a few years ago, where I operated 
somewhat reluctantly, the disease extended from above the 
clavicle to the floating ribs ; there were three large open 
ulcers connected by bridges of brawny tissue ; and the mass 
of semi-solid putrilage dug out filled an ordinary hand-basin ; 
yet this poor woman, almost at death's door, a nuisance to 
herself and family, recovered from the formidable operation, 
and enjoyed six months of ease and comfort before the dis- 
ease returned. In these days of anaesthesia, such a respite 
seems worth the risk incurred. A lotion of hydrate chloral 
(3j. to the, pint) may be safely used as a disinfectant and an- 
aesthetic to open sores. 

The following are the principal steps of the ordinary oper- 
ation. The patient reclines on a table, with her shoulders 
somewhat elevated, and the arm of the affected side extended. 
Two elliptical incisions, one below and one above the nipple, 
are made ; and if any of the axillary glands are contaminated, 
the lower incision should extend to the axilla. The whole 
of the mamma, down to the pectoralis major muscle, should 
invariably be removed, together with every particle of suspi- 
cious-looking tissue in the region. Few vessels need to be 
tied. After the first incisions, the gland is mainly enucleated 
15 



226 DISEASES OF WOMEN. 

with the operator's fingers, the handle of the scalpel, and a 
few light touches of the knife. After oozing has ceased, the 
surface may be painted with moderately strong carbolic acid, 
or a solution of bromine, and the necessary stitches inserted. 
A small drainage-tube of rubber, decalcified bone, or fine 
wire,' may be left in the lower angle of the wound. Dry 
absorbent cotton or wool, with a flannel roller-bandage over 
it, constitutes the best dressing. 

The entire operation may be performed under a cloud of 
carbolic acid spray, or, what is preferable, a stream of luke- 
warm water colored with permanganate of potass. 

Dr. Routh, senior physician to the Samaritan Free Hos- 
pital for Women, London, ^xo'^osqs gastric juice as a local 
remedy for cancer. He says, " After the whole or part of 
the diseased tissue has been removed, apply gastric juice. 
Morson's pepsin had a marked effect in dissolving sloughs 
which were formed naturally or were induced by artificial 
agents. It had a marked solvent effect up to a certain point 
upon the growths themselves. First, the cancerous growth 
should have its surface destroyed by Recamier's curette, a 
scoop, or the actual cautery. Then I apply gastric juice on 
lint. Next I cover this with a piece of oil-silk or gutta-percha 
sheeting, keeping all in its place by a piece of cotton. This 
should be done twice a day." He gives the details of several 
successful cases. 



^ Wire-drainage tubing is made by winding silver or iron wire around a small 
pencil. It can be prepared in a few minutes, and is pliant and serviceable. 



CHAPTER XXIII. 

CHLOROSIS — NEURASTHENIA — OVARITIS — 
CLITORIDECTOMY. 

CHLOROSIS. 

This Is a disease often confounded with anaemia, although 
really distinct from it. The peculiar greenish yellow color of 
the skin gives rise to the name. It occurs in girls about the 
age of puberty, and is generally associated with amenorrhoea. 
In many cases the blood is watery and deficient in red cor- 
puscles ; the large veins in the neck give out an anaemic 
bruit de diable, or venous hum, and the arteries (carotid and 
subclavian) sometimes a bellows murmur. The girl becomes 
languid and listless, complains of palpitation on slight exer- 
tion, is constipated, dyspeptic, despondent, and fretful. A 
common symptom is a depraved appetite, manifested by a 
liking for chalk, slate-pencils, or other unnatural diet. 

Pathologists are still divided as to the real cause of 
chlorosis, some setting it down as a neurosis primarily affect- 
ing the sympathetic system, and others considering it due to 
congenital malformation of the heart and blood-vessels. The 
fact that the disease is found more frequently among city than 
country girls points to the disease being acquired rather than 
inherited ; and even in cities the offspring of the well-to-do, 
who have plenty to eat, are fully as often affected as the 
children of the poor. In such girls, anaemia appears to be 
.an effect rather than a cause. 

Treatment. — If the disease is a neurosis, the most rational 
method will be to direct our remedies toward the improve- 



228 DISEASES OF WOMEN. 

ment of the ganglionic system. The constant current of 
electricity, massage, appropriate diet, and life in the open air, 
promise the best results. Even if anaemia should prove the 
main item in the sum total of drawbacks, a similar course of 
treatment would still be the best. In true chlorosis, not at- 
tended with appreciable deterioration of the blood, iron is 
seldom of service ; but where anaemia is present the saccha- 
rine carbonate may be tried in small doses. Horseback 
exercise, warm loose clothing, change of scene, and agreeable 
society, will do more good than medicine. It is not advisable 
to administer special emmenagogues. Unless some mechani- 
cal obstruction prevents the menstrual flow, it will be likely 
to make its appearance when the general health is re-estab- 
lished. 

NEURASTHENIA. 

This disease occurs most frequently in sterile women, mar- 
ried or unmarried, in whom the reproductive organs fail to 
fulfil their office, and the recoil chiefly afl"ects the nervous 
system. Dr. Beard, of New York, has pointed out that neu- 
rasthenia depends on mal-nutrition of the nerve-centres and 
nerves, followed by disturbances in the circulation, consist- 
ing of alternate local anaemia and hyperaemia, more especially 
in the pelvic organs. 

The symptoms complained of are backache, headache, in- 
framammary pain, shooting pains in the pelvic region and 
inside of the thighs, and a host of other ailments whose name 
is legion. In many cases the appetite is deficient or de- 
praved, and the blood becomes impoverished. 

Treatment. — If circumstances are favorable, the best 
method is to follow Dr. S. Weir Mitchell's directions in his 
useful little work, **Fat and Blood, and How to Make 
Them." It is difficult to determine whether the massage, the 
electricity, the forced feeding, or the moral management 
contributes most to the cure. There can be no doubt that 
such patients often become a terror to their physician and a 



OVARITIS. 229 

chronic pest to their relatives for lack of moral firmness on 
the part of those who have charge of them. A woman may 
be seriously injured by misplaced kindness as surely as by 
cruelty. An essential preliminary, therefore, is isolation 
from too sympathetic friends. This treatment requires the 
services of a trained nurse, able to employ massage, apply the 
primary electric current, cook well, and not accessible to 
tears or bribes. Dr. Mitchell commences with small quanti- 
ties of skimmed milk every hour, given the same as if it were 
a medicine (which it is in such a case), gradually increased in 
quantity ; after a few days, new milk is given at short 
intervals, sometimes as much as four quarts a day, to which 
a plain nutritious diet of eggs, chicken, steak, and fruit may 
finally be added. Twice every day the patient is rubbed, 
kneaded, and shampooed for an hour at a time ; and the 
primary current of a Hall's French battery applied all over 
for ten minutes night and morning. 



OVARITIS. 

The subject is confessedly an obscure one. Under this 
head may be ranked those doubtful affections of the ovary 
and Fallopian tubes which have not as yet been satisfactorily 
differentiated. During menstruation the ovaries are nor- 
mally congested and swollen, and a comparatively slight 
cause will produce inflammation. The increase in weight 
may induce prolapsus, possibly followed by inflammatory 
adhesions, which perpetuate the original hypersemia. The 
left ovary is more frequently affected than the right. The 
pressure of fseces (in the sigmoid flexure or rectum), and the 
more roundabout course of the left ovarian vein, which emp- 
ties its blood into the renal vein instead of into the vena cava, 
account for its greater tendency to congestion and inflam- 
mation. The Douglas cul-de-sac, too, is deeper on the left 
than the right side, so that there is a chance for the left ovary 
to sink lower. 



230 DISEASES OF WOMEN. 

One or both ovaries may enter the inguinal canal, consti- 
tuting single or double ovarian hernia. The celebrated case 
of Percival Pott, in which he removed both ovaries from the 
inguinal canals, is famihar to most surgeons. He says : ** A 
healthy woman, about twenty-three, was taken into St. 
Bartholomew's Hospital on account of two small swellings, 
one in each groin, which for some months had been so pain- 
ful that she could not do her work as a servant. The tumors 
were perfectly free from inflammation, were soft, unequal in 
their surface, and very movable. The woman was large- 
breasted, stout, and menstruated regularly. Mr. Nourse 
took all possible pains to return the parts through the open- 
ings, but found all his attempts fruitless ; and, the woman 
being incapacitated from getting her bread, and desirous to 
submit to anything for relief, it was agreed to remove them. 
. . . She has enjoyed good health ever since ; her breasts 
are gone ; nor has she menstruated since the operation, which 
is now some years." ^ 

Acute ovaritis is a rare disease ; but cases of a subacute or 
chronic character are not uncommon. Ovaritis may follow 
as a sequel to pelvic peritonitis, or it may directly result from 
gonorrhoeal infection, the virus passing through the Fallopian 
tubes. The hypersemia which precedes cystic growths in 
the ovary is almost always followed by a certain amount of 
inflammation. Endometritis, retroflexion and other dis- 
placements, sometimes act as reflex causes. Long-continued 
masturbation, or even an ill-balanced erotic mind, may lead 
to chronic ovaritis. When inflammation spreads to the 
Fallopian tubes, or commences there, the disease is called 
salpingitis. 

The distinctive symptoms, so far as known, are : pain in 
the groin, extending downward to the inside of the thigh, 
increased during or soon after defecation and at the men- 
strual periods ; nausea and vomiting ; flatulence, vertex 

^ Abridged from Pott's Chirurgical Works, vol. iii., 1783. 



CLITORIDECTOMY. 23 1 

headache, backache, and exquisite pain under bimanual pal- 
pation. 

Treatment. — Absolute rest is necessary in acute ovaritis ; 
more especially if we have reason to suspect that suppuration 
has occurred. Satisfactory evidence of fluctuation (the pa- 
tient being etherized) would warrant the use of the aspirator. 
If pus is found in the Douglas cul-de-sac, make a small open- 
ing with an Atlee's guarded knife, insert a dilator, and slowly 
enlarge the hole by tearing (which avoids the chance of cut- 
ting arteries). If a free vent is not made, there is some risk 
that the abscess may burst into the peritoneal cavity, an acci- 
dent likely to prove fatal. 

Chronic ovaritis is best treated by the application of four 
or more leeches near the cervix — behind it if possible ; small 
blisters in the groin, repeated daily for weeks ; potassium 
bromide in fifteen-grain doses internally, occasionally substi- 
tuting potassium iodide for the bromide. Rest should be 
ordered at the menstrual periods, beginning two days before 
and ending two days after the flow. Desperate cases may 
warrant the performance of Battey's operation. 

Ovarian hernia is generally congenital ; and when the 
gland cannot be returned, it should be removed, taking anti- 
septic precautions. 

CLITORIDECTOMY. 

The clitoris arises from beneath the ischio-pubic rami by 
the roots, which enlarge as they converge at about the level 
of the symphysis and form one body. The corpora caver- 
nosa thus blended are separated by a median septum, and 
are made up of a trabeculae of muscular and connective 
tissue. The blood is furnished by two arteries of consider- 
able size ; the veins emerge directly from the corpora caver- 
nosa. The nerve-supply is from the superior branch of the 
internal pudic, and is distributed to form several plexuses. 
The glans clitoridis is usually only a small tubercle covered 



232 DISEASES OF WOMEN. 

in by the juncture of the nymphae to form a sort of hood or 
prepuce. 

The clitoris, in common with all parts of the body, is sub- 
ject to a variety of diseases — cancer, enchondroma, syphilis, 
hypertrophy, atrophy — and to a part thus abundantly sup- 
plied with nerves, and, in a certain measure, acting as guar- 
dian to a most important class of functions, it would, a priori, 
appear probable, as is found in fact, to be liable to neurotic 
changes. 

Hypertrophy of the glans has been reported by several 
writers to rival in size the penis. This is very rare, and 
usually congenital. When congenital it is generally asso- 
ciated with other anomalies of formation. Increase of vascu- 
larity produces hypertrophy, gives rise to irritability of the 
pubio-vesical nerve-plexuses, and is a cause of erotic excita- 
tion, sometimes ending in nymphomania. Double clitoris 
results from arrest of the union of the two rami. These may 
be partially joined, and give rise to a perforation, or the for- 
mation of a cowl, which may extend into the urethra. 

It is highly probable that clitoridectomy will be seldom 
advisable. Considered as the centre of the ganglionic nerve 
forces which control sexual excitation, the removal of the 
clitoris has been thought by some observers to offer a rational 
and radical cure of nymphomania. Only a few cases of com- 
plete extirpation have been reported, and these so imper- 
fectly as regards the details of the operation, by which one 
might judge of its thoroughness or its subsequent history, that 
little can be learned of the value of the operation. 

To be effective clitoridectomy should include removal of 
the entire organ, not the glans only. This is. best effected by 
semilunar incisions commencing just anterior to the junction 
of the nymphae, and continued laterally to join in front of the 
urethra. This allows the division of the rami near their ori- 
gin. The hemorrhage is so great that it will be necessary to 
ligate each ramus. This should be done by animal ligatures 



CLITORIDECTOMY. 233 

cut short, and the wound closed, when primary union may be 
expected. 

The thought of sexually innervating women has aroused on 
the part of the profession a wholesale condemnation strange 
to account for, when we consider that castration of men seems 
to be thought a small matter, although the latter produces 
total sexual disability and the former does not. Mr. Raker 
Brown, of London, a surgeon who has made gynecologists his 
debtor, fell a victim to this unreasonable prejudice. 

In the case of a married woman, sixty years old, where the 
entire clitoris (which was about double the usual size) was 
removed, there was a constant and unrelieved sexual irrita- 
tion which threatened insanity. Six months have elapsed, 
and the patient is much better ; a very large portion of the 
time she is absolutely free from suffering. Dr. Graily Hewitt 
recently gave me details of an unreported case where complete 
extirpation of the clitoris had been performed. The patient 
was only about twenty and newly married. Sexual excite- 
ment was intense ; at times acute mania had supervened. 
The operation was not successful, — H. o. M, 



CHAPTER XXIV. 

STERILITY— HYSTERIA. 

STERILITY 

may be congenital or acquired. It is congenital and total 
only when the ovaries or uterus are absent at birth — a rare 
occurrence, of which I have seen only one case. These 
organs may be present, but remain in the undeveloped state 
natural before puberty ; the Fallopian tubes may be imper- 
vious ; or obstructions may exist at the os or cervix uteri 
which prevent the passage of spermatozoa to the corpus, one 
of the most frequent of which is cervical catarrh, blocking up 
the cervix with a plug of tenacious mucus. 

Sterility may be acquired after the birth of one or more 
children, and be due to malposition, to pelvic cellulitis or 
peritonitis, to salpingitis, to ovarian disease, or to poisonous 
secretions which kill the spermatozoa. Gonorrhoea in either 
sex is a frequent cause. 

Sterility may be the fault of the male, owing to absence of 
spermatozoa in the seminal fluid. This deficiency may be 
either congenital or acquired. Where the testicles do not 
descend into the scrotum (crypsorchis), spermatozoa are 
almost always absent. And after an attack of double orchitis 
the power of procreation is lost for months or years, it may 
be permanently. Stricture in the male urethra may so ob- 
struct the outward passage of semen that the fluid fails to 
reach the vagina. In all these cases there need be no im- 
potence on the part of the male. Impregnation does not 
absolutely require penetration. Cases of conception have 



STERILITY. 235 

frequently been observed in which real copulation never oc- 
curred. The essential element on the part of the male is the 
presence of spermatozoa in the semen, which may be depos- 
ited outside, but near enough to effect an entrance into the 
vagina. Erethism on the part of the woman has little or noth- 
ing to do with conception ; this may occur during a state of 
utter unconsciousness on her part. The nervous action neces- 
sary is mainly reflex, depending on the spinal cord more than 
the brain. 

Curable sterility seems to depend most frequently on mal- 
position of the uterus. Normally the womb occupies a posi- 
tion nearly at right angles to the vaginal entrance, the cervix 
slanting slightly backward. After the excitement of sexual 
intercourse a kind of general lassitude supervenes, in which 
the uterine ligaments participate, so that the os naturally 
sinks down into the pool of semen which has just been de- 
posited in the vagina. But if the womb is much anteverted 
or retroverted this does not occur ; the os is tilted out of 
reach. Where the vagina is shorter or more elastic than 
usual, the semen is immediately ejected by the recoil, and 
sterility results. The os may be a mere slit instead of a 
round opening, or the anterior lip elongated and act as a 
valve ; in either case the semen does not enter the womb. 
Or the vaginal secretions may be so acrid that the sperma- 
tozoa are killed before reaching their destination. 

Treatmejit. — The cure of sterility is surrounded with more 
difficulties than pertains to any other department of gyne- 
cology. The first step is to ascertain whether the female 
reproductive organs are in a healthy state. The surgeon 
must make an exhaustive examination, and proceed to rectify 
whatever he finds amiss. If there is vaginitis or endome- 
tritis, these affections should be cured. Marked retroversion 
or anteversion, a congested slit-like os, or a pinhole os, must 
be remedied- Dr. Ellwood Smith, of Philadelphia, strongly 
recommends rapid dilatation by means of a two-bladed dilator, 
of which he uses three sizes. They are successively intro- 



236 DISEASES OF WOMEN. 

t duced through the internal os and the canal fully dilated at 
one sitting. 

If sterility still persists, the husband should be examined, 
after Dr. Sims' method, to find out if spermatozoa exist in 
the semen. If he has suffered from gonorrhoea, complicated 
with orchitis, or from syphilis, the case may be set down as 
nearly hopeless, more especially if the parties have lived to- 
gether a long time. 

The adjuvants to success are, first, whatever tends to im- 
prove the general tone of the system, as gentle out-of-door 
exercise, salt-water hand-baths with rubbing, regular defeca- 
tion, and attention to diet ; and second, not too frequent 
sexual intercourse, choosing the two days immediately be- 
fore or immediately after menstruation. 

HYSTERIA. 

The name is apt to mislead one ; for the symptoms are not 
always traceable to the womb, and indeed may occur in men. 
They are more closely connected with the nervous system 
than the reproductive, and consist essentially of hyperaesthe- 
sia, manifesting itself in a multitude of forms. The disease is 
not confined, to the childbearing period, for it occurs occa- 
sionally before puberty and after the menopause. One of 
the most characteristic symptoms of hysteria is anaesthesia of 
the fauces ; in a hysterical girl a finger can be passed into 
the pharynx without exciting nausea. Our attention is early 
arrested by the protean character of the morbid phenomena, 
nearly every medical and surgical disease being closely sim- 
ulated. At first hysteria is marked by depression of spirits, 
suddenly alternated with undue exaltation — peals of wild 
laughter preceded by convulsive sobbing and moping. One 
of the most common sensations is that of a round body in 
the throat called ** the globus hystericus." 

Physicians who suppose that hysterical women are all ma- 
lingerers, make a great mistake. The disease is as real. 



HYSTERIA. 237 

though not as tangible, as pneumonia ; it is our first duty 
to search patiently and carefully until we find out the cause. 
Probably this affection depends more frequently on conges- 
tion, irritation, inflammation, or misplacement of the ova- 
ries, than on anything else, and occurs oftenest at or about 
the menstrual periods. Mr. Abernethy, the celebrated Lon- 
don surgeon, used to say that " irritability is little more than 
debility excited," and the remark applies to most cases of 
hysteria. 

Treatment. — Partly moral and partly medical. In what- 
ever way hysteria begins, there can be no doubt that after 
a time the mental balance is lost, and comparatively slight 
agencies explode the hysterical mine. Our first efforts, there- 
fore, should be directed to bracing the patient's mind, infus- 
ing hope and inspiring confidence. This will not be effected 
by ridicule. The patient must have faith in her physician, 
and she will not believe in him if he makes fun of her. A 
thorough examination is essential. If the ovaries are at fault 
they must be attended to. The bowels are almost always 
out of order, most frequently constipated. To obviate this, 
a rational diet scale should be prescribed and enforced ; 
gentle exercise in the open air, and mild laxatives if neces- 
sary. Great benefit often follows the daily employment of 
a primary current of electricity for fifteen or twenty minutes. 
Bromide of sodium (grs. xvi.) in half a gobletful of ice-water, 
at bedtime, sometimes produces a good effect. A sponge- 
bath should be given every night and morning. Dr. Mitch- 
ell's method, already referred to, may be employed in obsti- 
nate cases, especially where "only" daughters have been 
pampered and spoiled by wealthy parents. 



INDEX. 



Abdominal pregnancy, 163 
supporter, loi 
Abernethy on hysteria, 237 
Abortion, 160 

criminal, 162 
Abrasion of cervix, 70 
Abscess lancet, 151 
Abscess, pelvic, 88 
Absorbent cotton or wool, 33 
Actual cautery to sever pedicle, 136 

in cystitis, 188 
Acute cystitis, 184 

endometritis, 80 
metritis, 75 
Agalactia, 154 
Ala vespertilionis, 26 
Albert Smith pessary, 79, 97 
Albumen in ovarian fluid, 125 

urine, 147 
Albuminuria, 148 
Alimentation, rectal, 169 
Alopecia, syphilitic, 211 
Alum, 47 
Amenorrhcea, 58 
Anal fissure, 198 
Analgesia in syphilis, 21 1 
Anatomy of genital organs, 17 
Anteflexion, loi 
Anteversion, 99 

pessary, 100 ■ 
Application of remedies, 39 
Applicator, 38 
Arbor titae, 24 
Artificial fistula for cystitis, 186 



I Ascites, 126 
Ashford on metritis, 75 
Asthenic peritonitis, 140 

puerperal fever, 146 
Atlee, W. L., 130 
Atresia vaginas, 53 
Aveling on leucorrhoea, 47 
Ayres' case of extroversion, 195 



Bache, Emmet's fistula tube, 187 
Baker Brown on ovariotomy, 136 
Barnes on dyspareunia, 50 

elongation of cervix, 106 
Bassareau on syphilis, 212 
Battey's operation, 143, 231 
Beard on neurasthenia, 228 
Bellows murmur in chlorosis, 227 
Benzoate ammonia in cystitis, 185 
Bichloride of mithylene, 133 
Bigelow, H. J., litholapaxy, 189 
Bimanual examination, 34, 60 
Bistoury, Syme's abscess, 151 
Bixby, G. H., on pruritus, 45 
Black silk ligatures, 137 
Bladder, anatomy of, 18 
Bleedmg piles, 196 
Blennorrhoea, 43 
Blind piles, 196 
Blistering, new mode of, 76 
Block-tin pessaries, 78 
Blunt needle to ligate pedicle, 136 
Bowstead on convulsions, 149 
Broad ligaments, 25 



240 



INDEX. 



Bromide of iodine, 78 
Bulb of vagina, 21 
Bumstead on syphilis, 210 
Burnham, Walter, cases, 124 
Burns on vaginismus, 50 
Buttles' intra-uterine syringe, 66 
Byford's linen pessaries, 41 



Cancer of the breast, 224 
ovary, 222 
uterus, 219 
vagina, 222 

Cancroid, 221 

Carbolic acid, 39 

Carbolized tent, 77 

Carbonic acid as a sedative, 62, 220 

Caruncles, 191 

Case for vials, 32 

Catarrh of vagina, 44 

Catheter, how to introduce, 19 
double, 76 
Skene's reflux, 191 

Cauliflower excrescence, 221 

Cauterizing iron, 136 

Cautery clamp, 136 

Cellulitis, pelvic, 86 

Celluloid speculum, 36 

Cervical endometritis, 79 
metritis, 77 

Cervix uteri, 23 

Cesarean operation, 165, 222 

Chad wick's office- table, 33 

Chancre, 208 

Chancroid, 206 

Chapped nipples, 153 

Chassaignac's ecraseur, 136 

Chloral in convulsions, 149 

Chloroform in convulsions, 148 

Chlorosis, 227 

Chromic acid, 39 

Chronic cystitis, 184 

endometritis, 80 
metritis, 77 

Clamp for pedicle, 135 



Clap, 202, 205 

Clay, Charles, ovariotomy, 124 

Cleansing the parts, 37 

Clitoridectomy, 231 

Clitoris, 30, 221 

Clonic spasms, 147 

Cloth tents, 77 

Coccyodynia, 175 

Coffee- colored syphilide, 211 

Colpitis, 43 

Concealed hemorrhage, 167 
I Condylomata, syphilitic, 212 
j Congenital syphilis, 215 
' Constitutional syphilis, 210 

Convulsions, puerperal, 147 
' Copeman on dilatation of cervix, 170 

Copulation not essential, 234 

Corneitis in syphilis, 216 

Corporeal endometritis, 81 
metritis, 77 

Corpus luteum, 28 
uteri, 23 

Cotton pessary, 41 

Crede's method with placenta, 162 

Crypsorchis, 234 

Cupper for cervix, S^ 

Curable sterility, 235 

Curette, Sims', 68 

Cusco's speculum, 35 

Cutter's anteversion pessary, 100 
retroversion pessary, 97 
ring pessary, 108 
tubes for ecraseur, 119 

Cutter on electrolysis, 123 

Cystitis, 184 

Cystoma, 125 



Danger of uterine injections, 39 

Day's case of retained sponge, 48 

Death from tetanus, 121 

Deficient secretion of milk, 154 

Denidation, 59 

Dermoid cysts, 125 

Deville on granular vaginitis, 43 



INDEX. 



24] 



Diagnosis of ovarian tumors, 126 
Dilatation of cervix, in vomiting, 170 

in menorrhagia, 68 
ostium vaginae, 49 
ureters, 185 
Dilator, ElHnger's, 69 
Diseases of bladder, 184 
rectum, 196 
urethra, 190 
Dislocation of urethra, 20, 195 
Diuretic action of chloroform and ether, 

149 
Double catheter, 76 
Douglas' sac, 22, 26, 91, 229 
Drainage tubes, 140, 226 
Dropsy of ovary, 125 
Drysdale's ovarian cell, 125 
Dysmenorrhoea, 62 
Dyspareunia, 50 



EcRASEUR, Chassaignac's, 136 

wire, 116 
Electricity in amenorrhoea, 60 
Electrolysis, 123 
ElHnger's dilator, 69 
Elliott's case of urethral prolapsus, 194 
Elongation of cervix, 105 
Embolism, 176 
Emmet on atresia vaginas, 55, 57 

cystitis, 186 

eversion of cervix, 71, 73 

inversion, 11 1 

vaginal injections, 41 
fistula, 179 

vaginismus, 50 
Emmet's intra-uterine syringe, 65 
Encephaloid cancer, 219 
Endometritis, 79 
Enema of glycerine, 197 
Enlargement of glands in syphilis, 209, 

212 
Entero-vaginal fistula, 181 
Enucleation of pedicle, 136 
Epithelioma of cervix, 221 
16 



Epitrochlear glands in syphilis, 212 
Ether as a diuretic, 149 
Excess of urea in blood, 148 
External uterine tumors, 114 
Extra-peritoneal blood-tumors, 91 
Extra-uterine gestation, 163 
Extroversion of bladder, 194 



Falling of the womb, 103 
Fallopian tubes, 23, 29 
Fecal accumulations, 128 
Fergusson's speculum, 36 
Fermented liquors to be avoided in 

gonorrhoea, 204 
Fever, puerperal, 145 
Fibro-cystic tumors, 115 
Fibroid tumors, cases, 118 

in colored women, 115 
Field, H. M., on general treatment, 82 
Fissure at neck of bladder, 185 
Fistula, entero-vaginal, 181 

from stone in bladder, 179 
neglected pessaries, 1 79 

how to detect, 179 

recto- vaginal, 181 

vesico-vaginal, 178 
Fixation a sign of cancer, 218 
Fluor albus, 45 
Forceps, polypus, 116 
torsion, 132 
uterine, 32 
Fordyce Barker on puerperal fever, 146 
Fountain syringe, 41 
Fourchette, 22 

Fournier on secondary syphilis, 211 
Fumigation with mercury, 217 



Galactorrhcea, 155 
Galvano-cautery, 107 
Gangrene of bladder, 96 
Gastric juice in cancer, 226 
Genital organs, anatomy of, 17 
Gerould on bromide of iodine, 78 



242 



INDEX. 



Glands in vagina, 21 

Glans clitoridis, 30, 232 

Glass pipette, 39 

Globus hystericus, 236 

Glovers' needles, 137 

Glycerine as an enema, 197 

Gonorrhoea, 42, 202 

a cause of sterility, 234 

Gonorrhoeal cervicitis, 203 

ophthalmia, 205 
rheumatism, 205 

Gooch on irritable uterus, 62 

Gouley on cystitis, 186 

Graafian follicles, 27 

Graefe, Von, on syphilitic iritis, 212 

Granular vaginitis, 43 

Graves' case of lacerated cervix, 73 

Gummy tumors of breast, 214 

Gynecological table, Chadwick's, 33 



HEMATOCELE, pelvic, 90 

Haematometra, 58 

Harlow's case of concealed hemorrhage, 

168 
Hemorrhage after ovariotomy, 139 

puerperal, 167 
Hemorrhoids, 196 
Hepatic cyst, 128 

pills, 63, 82 
Hereditary insanity, 150 
syphilis, 215 
Hernia director, 132 
History of ovariotomy, 124 
Hjaltelin on leucorrhoea, 46 
Hodge's lever pessary, 78 
Hot bran-bags, 151 
Hot salt-bags, 62, 132, 138 
Hot water as a styptic, 137 
Hot-water bottle in mastitis, 151 

injections, 40, 103, 159 
Hugier on vulvitis, 42 
Hunter, John, on hsematocele, 91 
Hutchison on syphilitic children's teeth, 
216 



Hydrobromic acid in cystitis, 185 
Hydrocyanic acid in convulsions, 149 
Hymen, anatomy of, 29 
Hypercarbonized blood, 160 
Hypertrophic elongation of cervix, 105 
Hypertrophied omentum, 128 
Hypodermic injections of brandy or 

ether, 132, 138 
Hysteria, 236 
Hysterical urine, 19 



Iced champagne, 139 
Ice-pills in vomiting, 139 
Ice-poultice, 155 
I Imperforate hymen, 30, 53 
Incontinence of urine, 179 
Incubation of syphilis, 208 
Indurated omentum, 128 
Induration of glands in chancre, 209 
Infantile womb, 60 
Inflammation of cervix, 70 
Inflammatory dysmenorrhoea, 63 
Infravaginal elongation of cervix, 105 
Infusion digitalis, 149 

triticum repens, 185 
Injections in cystitis, 186 

ovarian cysts, 130, 140 
of hot water, 40 
iodine, 130 
Inoculation a test for chancroid, 207 
Insanity, puerperal, 150 
Insensibility in septicaemia, 92 
Insertion of speculum, 35 
Instruments, how to use them, 32 
Intermenstrual dysmenorrhoea, 66 
Internal uterine tumors, 1 14 
Intraperitoneal blood-tumors, 90 
Intra-uterine scarificator, 63 

stem-pessary, 99, 102 
Inunction of mercury, 216 
Inversio uteri, 100 

hemorrhage from, no 
Iodide of phenol, 39 
starch, 214 



INDEX. 



243 



Iodine injections in ovarian cysts, 130 
Iritis, syphilitic, 212 
Iron cotton, 72 
Irritable uterus, 62 



Jaborandi in convulsions, 149 

James' styptic, 72 

Junker's apparatus for methylene, 133 

Keith on ovariotomy, 131 
Keyes on syphilis, 211 
Kidneys in cystitis, 185 
Kimball, Oilman, ovariotomy, 124 
Kitchen table to operate on, 33 

Lacerated cervix, 71, 73, 172 

perineum, 173 

vagina, 172 
Lacerations of uterus, 71, 172 

vagina or vulva, 172 
Lacteal metastasis, 157 
Laminaria tents, 100 
Laxative pills, 81 
Leucorrhoea, 45 
Linen pessaries, 41 
Litholapaxy, 189 
Longitudinal vaginal septum, 55 
Loop pessary, 97, 100 
Low peritonitis, 140 
Lyman, G. H., on cervical dilatation, 69 

MACLEOD- on ulceration, 71 
McDowell, ovariotomy, 124 
Mammary glands, 30 

cancer of, 224 
Marasmus from syphilis, 216 
Marriage after syphilis, 216 
Martin, H. A., rectal polypus, 199 
Martin's rubber bandage, 157 
Mastitis, 151 
Mastodynia, 152 
Masturbation, 51 
Meatus urinarius, 18 



Melancholia, 150 
J Membranous dysmenorrhoea, 65 
j Menopause, 27 
I Menorrhagia, 66 
I Methylene, bichloride, 133 

Metritis, 75 

Metrorrhagia, 68 

Milk leg, 156 
1 Miner, J. F., on enucleation, 136 

Minot, F., case of embolism, 176 

Miscarriage, 160 

Missed labor, 166 

Mixed sore, 207 

Mode of examination, 33 

Mole pregnancy, 166 

Monocystic ovarian tumors, 125 

Monsel's styptic, 116, 136 

Morning sickness, 168 

Morphia and aconite in convulsions, 149 

Morson's pepsin, 226 

Morsus diaboli, 29 

Mucous patches, 212 
polypi, 115 

Needles, glovers', 137 

Nelaton's vulsellum, 132 

Neugebauer's speculum, 37 

Neuralgic dysmenorrhoea, 62 j 

Neurasthenia, 228 

Nidation, 59 

Nipples, chapped, 153 

a seat of chancre, 208 
retracted in cancer, 224 

Nitric acid, 39 

Nitrous oxide gas, 133 

Noeggerath on albuminuria, 149 
inversion, no 

Numbness in cervical inflammation, 71 

Obstructive dysmenorrhoea, 64 
Odor of vaginal mucus, 21 
CEdema of abdominal walls, 128 
Oleate of mercury, 213 
Onanism, 51 



244 



INDEX. 



Onychia, syphilitic, 210 
Operating table, Chadvvick's, 33 
Operation for lacerated cervix, 73 
Ophthalmia from syphilis, 216 
Os uteri, 23 
Ovarian pregnancy, 164 

tumors, diagnosis of, 126 
history of, 124 
• pathology of, 125 

with pregnancy, 127 
Ovaries, anatomy of, 27 
Ovariotomy, 131 
Ovaritis, 204, 229 
Oviducts, 29 
Ovisacs, 27 
Ox-gall pills, 192 



Papilloma, 221 
Papular eruptions, 211 
Paquelin's thermo-cautery, 107 
Paralbumen in ovarian fluid, 126 
Paralysis of sphincter ani, 197 

vesicae, 179 
Parametritis, S6 

Pathology of ovarian tumors, 125 
Peaslee on ovariotomy, 124, 140 
Pedicle in ovarian tumors, 134 
Pelvic abscess, 88 

cellulitis, 86 

hsematocele, 90 

peritonitis, 85 
Perimetritis, 86 
Perineum, lacerated, 173 
Peritonitis after ovariotomy, 139 

pelvic, 85 
Peri-uterine hsematocele, 90 
Persistent vomiting, i68 
Pessary in bladder. 20 
Phantom tumors, 128 
Phlegmasia dolens, 156 
Phosphatic deposits, to remove, 180 
Pike, Chas. C, case, 48 
Piles, bleeding and blind, 196 

internal and external, 196 



Pin in vagina, 48 

Pinkham's case of rectocele, 201 

Pipette, glass, 39 

Placenta, how to extrude, 162 

Placenta praevia, 167 

Plastic effusion, 85 

Plugging the vagina, 161 

Polycystic ovarian tumors, 125 

Polypi, 115 

Polypus forceps, 116 

Position when using Sims' speculum, 34 

Post, A. C, on cystitis, 188 

Post -cervical glands in syphilis, 212 

Potassium, chlorate, 162 

permanganate, 46, 76, 186 
Precautions in using strong acids, 39 
Pregnancy, extra-uterine, 127 
Pregnancy mistaken for ovarian tumor, 

127 
Premature birth, 160 
Preparations for ovariotomy, 131 
Priestley on intermenstrual dysmenor- 

rhoea, 66 
Probang, split, 38 
Procidentia uteri, 104 
Prof. Byford's hints, 38, 41 
Prolapsus of urethra, 194 

uteri, 103 
Pruritus vulvas, 44 
Ptyalism, 171 
Puerperal convulsions, 147 

delirium, 150 

diseases, 145, 160 

hemorrhage, 167 

insanity, 150 

lacerations, 172 

mania, 150 
Purulent ophthalmia, 205 
Pyaemia, 93 



Quinine, 146, 149 



Rapid fanning to stop emesis, 139 



INDEX. 



245 



Rectal alimentation, 169 

polypus, 199 
Rectocele, 200 
Recto-vaginal fistula, 181 
Rectum, 18 
Reflux catheter, 191 
Relaxation of pelvic joints, 174 

pills, 81 
Remedies applied by patient, 40 * 
Renal cysts, 128 
Rents in vagina, 172 
Retained placenta, 162 
Retroflexion, 98 
Retro-uterine hematocele, 90 
Retroversion, 95 
Ricord on gonorrhoea, 203 
Ring pessary, 105 
Roseola, syphilitic, 211 
Round ligaments, 26 
Routh on cancer, 226 
Rupture of uterus, 172 



Salpingitis, 230 

Salt-bags for dry heat, 62, 132, 138 

Satchel, 32 

Scarifications, 72 

Scarificator, Pinkham's, Gt,, 80 

Schroeder on cervix uteri, 105 

puerperal fever, 146 
Scirrhus, 218 

Sebaceous glands in vagina, 22 
Secondary syphilis, 210 
Septicaemia, 92, 198 
Serpiginous chancroid, 207 
Shock after ovariotomy, 138 
Silk ligatures, black, 137 
Simon on ulceration, 70 
Simpson, Sir James, on tetanus, 122 
Simpson's uterine sound, 38 
Sims' sharp curette, 68 

sigmoid catheter, 181 

speculum, 36 

vaginal dilator, 50 
Sims on vaginal fistula, 178 



Sims on vaginismus, 49 

Skene on cystitis, 185 

Skene's reflux catheter, 191 

Skimmed milk, 149, 229 

Slippery-elm tents, 100 

Smith's uterine dilators, 235 

Spasm of sphincter vaginae, 20 

Spaying, 143 

Speculum, Cusco's, 35 

Fergusson's, 36 
Neugebauer's, 36, 37 
Sims', 36 

Spencer Wells on ovariotomy, 124, 133, 

136 
Spermatozoa, absence of, 234 
Splenic cyst, 128 
Split probang, 38 
Sponge left in vagina, 48 
Sponges used in ovariotomy, 132 
Sponge-tents, 117 
Squamae in syphilis, 211 
Stem pessaries, 99, 102 
Sterility, fault of the male, 234 

from anteflexion, loi 
Stevens, Wm, F., atresia, 56 

fibroid polypus, 121 
Sthenic puerperal fever, 146 
Stone in the bladder, 189 
Storer, H. R., cases, 20, 52, 119 
Stricture of urethra, 192 
Styptic, James', 72 

Monsel's, 116, 136 
Subinvolution, 157 
Submucous fibroids, 1 14 
Subperitoneal fibroids, 114 
Supravaginal elongation of cervix, 105 
Syphilis, 206, 208 

a cause of abortion, 216 

constitutional, 210 

hereditary, 215 

secondary, 210 

tertiary, 213 
Syphilitic bubo, 209 

cachexia, 215 
erythema, 211 



246 



INDEX. 



Syphilitic fever, 211 

teeth in children, 216 
Syphilophobia, 215 
Syphon trocar, 129 
Syringe, intra-uterine, 66 
vaginal, 37 



Table for examination, 33 
Taliafero's cloth-tents, 77 
Tannate of glycerine, 47 
Tannin suppositories, 47 
Tapping ovarian cysts, 129 
Temporary delirium, 150 
Tenaculum, 32 
Tenesmus in urethritis, 190 
Tertiary syphilis, 213 
Tetanus, death from, 121 
Thomas' anteversion pessary, 101 

cupping cylinder, 83 
Thornton on ovarian fluid, 125 
Thrombosis, 176 
Toilet of the peritoneum, 137 
Tonic spasms, 147 
Torsion forceps, 132 
Triticum repens, 185 
Trocar for ovarian cysts, 129 
Tubal pregnancy, 29, 163 
Tunica albuginea, 28 
Tyler Smith on inversion, no 



Unilocular ovarian tumors, 125 

Ureters, occlusion of, 185 

Urethra, 19 

dilatation of, 20, 191 
used for coitus, 20 

Urethral prolapsus, 194 
stricture, 192 
tumors, 191 

Urethritis, 190, 202 

Urethrocele, 195 

Uterine cancer, 219 

dilators, 69, 235 
displacements, 95, 103 



Uterine fibroids, 1:4 
! forceps, 116 

ligaments, 25 

scarificator, 6;^ 

sound, 38 

tumors, 114 
Utero -sacral ligaments, 26 
Utero-vesical ligaments, 26 
Uterus, 18, 22 

contractions during gestation, 
160 



Vagina, 18, 21 
Vaginal douche, 40 

fistulas, 178 

glands, 21 

injections, 40 

ovariotomy, 141 
Vaginismus, 49 
Vaginitis, 43, 203 
Van Buren's method of paralyzing the 

sphincter ani, 197 
Varicose veins, hemon-hage from, 167 
Vaseline, i6i 
Venous hum, 227 
Vesicles in syphilis, 211 
Vesico -vaginal fistula, 178 

artificial, 186 
Virchow's nomenclature, 86 
Vulsellum, 132 
Vulva, 18 

Vulvar haematocele, 91 
Vulvitis, 42 



Walshe on cancer, 224 
Warren, J. Collins, cystitis, 188 

J. Mason, hemorrhoids, 198 
rectal polypus, 199 
Warty excrescences in urethra, 191 
Washing hands before examination, 34 
Weight of uterus, 25 
Wells, T. Spencer, ovariotomy, 124, 
133. 136 



INDEX. 



247 



33 

inversion. 



West on gonorrhoea, 203 

Whalebone sound, 

White, Jas. P., 

Whites, the, 45 

Wing, Clifton E., inversion, i: 

Winsor on imperforate hymen, 



54 



Wire curette, 67 

drainage-tubes, 226 
ecraseur, 116 
! Womb, 22 
I Wooden clamp, 135 
I Wool for dressings, 33 



